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J Thorac Cardiovasc Surg 2002;124:642-643
© 2002 The American Association for Thoracic Surgery

Letters to the Editor

Esophageal injury during radiofrequency ablation for atrial fibrillation: Inherent safety of radiofrequency bipolar coagulation

Anil M. Patwardhan, MD, MS, Vidyadhar S. Lad, MS, MCh, Vasudev Pai, MS

Department of Cardiovascular and Thoracic Surgery, K.E.M. Hospital, Parel, Mumbai—400 012, India

To the Editor:

We have read with interest the brief communication by Gillinov and associatesGo 1 titled "Esophageal Injury During Radiofrequency Ablation for Atrial Fibrillation," appearing in the December 2001 issue of the Journal. This communication highlights the danger of extension of thermal injury to adjacent structures when radiofrequency is used in the unipolar mode. Similar experience resulting in a fatality was presented by Mohr and associatesGo 2 at the 81st annual session of The American Association for Thoracic Surgery in May 2001.

We have used radiofrequency in the bipolar mode for replacing most of the incisions of the Cox maze III procedure for treating chronic atrial fibrillation since August 1996.Go 3 We reported our experience with 62 patients at the 20th annual sessions of the North American Society of Pacing and Electrophysiology,Go 4 with restoration of normal sinus rhythm in 46 (82.1%) of 56 survivors. We did not observe any complication related to thermal damage of adjacent tissues, as the effects of radiofrequency current are essentially confined to the tissue between the two tips of the bipolar forceps, that is, the atrial wall in this case.

Gillinov and associatesGo 1 undoubtedly deserve appreciation for highlighting a potentially lethal complication of unipolar radiofrequency ablation of the left atrial wall. The safer bipolar mode has not been used by anyone else to our knowledge, probably because of the fear that it is technically more demanding. We have treated more than 150 patients to date and have found that the technique for replicating the Cox maze procedure is easily reproducible by junior staff surgeons. The bipolar mode is a standard part of the surgical radiofrequency generator available in the operating room, free of additional cost, as compared with the expensive pens or probes used in the unipolar mode. Moreover, these devices need to be used with specially manufactured radiofrequency generators, which are also expensive.

This cost benefit is certainly of great significance in countries with limited resources. We hope that the report by Gillinov and associatesGo 1 may persuade surgeons to use radiofrequency in the bipolar mode when treating patients with atrial fibrillation.

There is a trend to use cryothermal ablation in treating atrial fibrillation because it is taken to be a safe ablative modality. This is because cryothermal tissue injury preserves basic tissue architecture and can be effective when applied epicardially on the beating heart, without the risk of thrombus formation on the endocardial surface.Go 5 Yet, the cryolesion progresses through (1) the freeze-thaw phase, (2) the hemorrhagic and inflammatory phase, and (3) the replacement fibrosis phase. Cryothermal ablation has been used in surgical treatment of arrhythmias since the late 1970s, but these were localized ablations. Extensive application of cryothermia would be necessary to replicate the maze procedure. It is important in this context to note the factors affecting the size of the cryolesion: (1) temperature, (2) size of the probe, and (3) duration of the freeze/thaw cycles.

We caution the readers against the extensive use of cryothermia on the left atrial posterior wall, in light of the knowledge that the cryolesion heals with fibrosis. Also, the occurrence of recto-urethral fistula after cryothermal application to the prostate, although rare, should prompt us to take appropriate care during left atrial ablations. We would recommend the use of an insulating pad behind the left atrium when a cryolesion is applied endocardially.

12/8/124672

doi:10.1067/mtc.2002.124672

References

  1. Gillinov AM, Pettersson G, Rice TW. Esophageal injury during radiofrequency ablation for atrial fibrillation. J Thorac Cardiovasc Surg. 2001;122:1239-40.[Free Full Text]
  2. Mohr FW, Fabricius AM, Falk V, Autschbach R, Doll N, von Oppell U, et al. Curative treatment of atrial fibrillation with intraoperative radiofrequency ablation: Short-term and midterm results. J Thorac Cardiovasc Surg. 2002;123:919-27.[Abstract/Free Full Text]
  3. Patwardhan AM, Dave HH, Tamhane AA, Pandit SP, Dalvi BV, Golam KK, et al. Intraoperative radiofrequency microbipolar coagulation to replace incisions of the Maze III procedure for correcting atrial fibrillation in patients with rheumatic valvular disease. Eur J Cardiothorac Surg. 1997;12:627-33.[Abstract]
  4. Patwardhan A, Kumar N, Dave H, Pandit S, Golam K, Dalvi B, et al. Efficacy of radiofrequency coagulation to replace Cox's Maze incisions in restoring sinus rhythm in patients with rheumatic valvular disease and atrial fibrillation (abstract). Pacing Clin Electrophysiol. 1999;22:847.
  5. Lustgarten DL, Keane D, Ruskin J. Cryothermal ablation: mechanism of tissue injury and current experience in the treatment of tachyarrhythmias. Prog Cardiovasc Dis. 1999;41:481-98.[Medline]



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