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J Thorac Cardiovasc Surg 2003;125:836-842
© 2003 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

Esophageal perforation during left atrial radiofrequency ablation: Is the risk too high?

Nicolas Doll, MDa, Michael A. Borger, MD, PhDa, Alexander Fabricius, MDa, Susann Stephan, MDd, Jan Gummert, MD, PhDa, Friedrich W. Mohr, MD, PhDa, Johann Hauss, MD, PhDc, Hans Kottkamp, MD, PhDb, Gerd Hindricks, MD, PhDb

From the Clinic for Heart Surgery, Heart Center,a Clinic for Cardiology/Electrophysiology, Heart Center,b Clinic for General Surgery,c and Department of Pathology,d University of Leipzig, Leipzig, Germany.

Received for publication April 26, 2002. Revisions requested July 8, 2002; revisions received July 30, 2002. Accepted for publication Aug 6, 2002. Address for reprints: Nicolas Doll, MD, Heart Center, Clinic for Cardiac Surgery, University of Leipzig, Strümpellstrasse 39, 04289 Leipzig, Germany (E-mail: dolln{at}medizin.uni-leipzig.de).

Objective: Intraoperative radiofrequency ablation of atrial fibrillation (IRAAF) is a recently developed procedure being performed in an increasing number of patients. We have performed left atrial IRAAF in 387 patients since August 1998. The purpose of this article is to describe a serious complication of this procedure, namely IRAAF-induced esophageal perforation, in detail to identify possible risk factors.
Methods: Left atrial IRAAF was performed with a commercially available unipolar probe as an isolated procedure (n = 129) or in combination with mitral valve surgery (n = 163) or other surgical procedures (n = 95). Operations were performed either through a conventional sternotomy or right minithoracotomy.
Results: Four (1%) patients had esophageal perforation after radiofrequency ablation. All 4 patients presented after an initially unremarkable postoperative course, with sudden neurologic symptoms from esophagoatrial air embolization occurring in 3 of the patients. Three patients were successfully treated with extensive esophageal resection, and one died from massive air embolism. All perforations occurred in patients undergoing minimally invasive IRAAF. Comparison with other patients undergoing isolated minimally invasive IRAAF (n = 129) failed to reveal any reliable predictors of esophageal injury, including patient body size, operating times, or radiofrequency biophysical parameters.
Conclusions: Left atrial IRAAF is associated with a small but definite risk of esophageal perforation. Unfortunately, we were unable to identify any risk factors for this life-threatening complication. A high degree of vigilance must be maintained for esophageal injury after IRAAF, particularly in patients with new neurologic deficits. Until safer methods of ablation are developed, we currently recommend against the use of IRAAF in patients undergoing cardiac surgery.




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