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J Thorac Cardiovasc Surg 2003;125:836-842
© 2003 The American Association for Thoracic Surgery
Surgery for Acquired Cardiovascular Disease |
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).
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Abstract |
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 Top Abstract IntroductionMethodsResultsDiscussionPost-IRAAF esophageal injury: A...ConclusionsReferences |
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Introduction |
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TopAbstractIntroductionMethodsResultsDiscussionPost-IRAAF esophageal injury: A...ConclusionsReferences |
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1 Several investigators have described encouraging results with intraoperative radiofrequency ablation of the left atrium, achieving curative rates of approximately 80%. 2-4 Electrophysiologists have also successfully performed radiofrequency ablation for atrial fibrillation with percutaneous catheter-based techniques. 5
We have previously reported on our experience with IRAAF, 4,6-8 and the current study includes a total of 387 patients treated in this manner. The focus of this report, however, is on a particularly serious complication that we have observed in 4 of these patients (ie, radiofrequency-induced esophageal perforation). Recently, Gillinov and coworkers 9 described a single case of esophageal perforation after intraoperative left atrial radiofrequency ablation. Because we have now observed 4 of these same complications, we wanted to gain insight into the mechanisms of this potentially life-threatening injury. Therefore the purpose of this article was to describe these 4 patients in detail and to discuss whether the risks of esophageal injury are prohibitively high for this procedure. Our findings might have significant implications for both surgical and catheter-based radiofrequency atrial ablation procedures.
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Methods |
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TopAbstractIntroductionMethodsResultsDiscussionPost-IRAAF esophageal injury: A...ConclusionsReferences |
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Patient characteristics
Four (1%) of 387 patients had perforation of the esophagus. These 4 patients all underwent IRAAF by using minimally invasive techniques. We therefore focused our analysis on patients undergoing minimally invasive isolated IRAAF (n = 133). The preoperative characteristics of these patients are presented in Table 1.
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Patient 2 was a 62-year-old woman with a secundum atrial septal defect and chronic permanent (ie, unresponsive to cardioversion) atrial fibrillation. One year before the operation, the patient had progressive dyspnea and underwent cardiac catheterization. An atrial septal defect was diagnosed, with a left-to-right shunt of 1.5 to 1. Coronary angiography and left ventricular function was normal (ejection fraction of 60%). The left atrium was significantly enlarged (53 mm).
Patient 3 was a 59-year-old man with a 10-year history of atrial fibrillation that was permanent for the last 3 years. Four different antiarrhythmic agents had proven ineffective (flecainide, propafonone, amiodarone, and sotalol), and several electrical cardioversions resulted in relapse to atrial fibrillation within weeks. The patient had no organic heart disease (normal coronary arteries, ejection fraction of 62%), and the left atrium was moderately enlarged (44 mm).
Patient 4 was a 36-year-old man with paroxysmal atrial fibrillation. The patient was highly symptomatic during his episodes of atrial fibrillation, which would last 6 to 36 hours. Antiarrhythmic drug treatment with flecainide was not effective. Treatment with amiodarone was recommended to the patient; however, he did not want long-term medical therapy and preferred curative surgical treatment. The patient had no organic heart disease, ejection fraction was 68%, and the left atrium measured 42 mm in diameter. The patient had undergone partial gastric resection because of recurrent bleeding gastric ulcers several years prior.
Surgical procedure and radiofrequency ablation
Details of the surgical procedure have been reported elsewhere. 4,6-8 In patients undergoing minimally invasive IRAAF, a right lateral minithoracotomy (4-6 cm) was performed in the fourth intercostal space, and cardiopulmonary bypass was established through femoro-femoral cannulation. Direct aortic clamping was performed with a transthoracic clamp (Chitwood Clamp; Scanlan, Minnesota, Minn) inserted percutaneously in the second intercostal space. The left atrium was incised parallel to the mitral annulus close to the interatrial groove.
Radiofrequency energy was applied with a specially designed hand-held probe with a 10-mm T-shaped electrode tip (Radios 504; Osypka GmbH, Grenzach-Wyhlen, Germany). 6 The electrode tip contained a thermistor for temperature-controlled energy application. Radiofrequency ablation was performed in a unipolar mode between the tip and an external backplate electrode. Power, impedance, and catheter tip temperature were continuously monitored and recorded. On the basis of the results of experimental studies, the preselected target catheter-tip temperature was 60°C, and the duration of energy application was 20 seconds after the target temperature had been achieved. 10 A continuous lesion line was created extending from the inferior aspect of the mitral annulus (P3) to the left lower pulmonary vein. Separate lesion lines were created between the left upper and lower pulmonary vein orifices, between the left and right upper pulmonary vein orifices, and between the right upper and lower pulmonary vein orifices. 11,12 The number of radiofrequency applications required to complete these lines depended on the size of the left atrium. Care was taken not to extend the lesions into the pulmonary veins. After radiofrequency application, the left atrial incision was closed, and the patients were weaned from cardiopulmonary bypass in the usual manner.
Statistical analysis
Results are given as means ± SD for continuous variables and as percentages for categoric variables. Data were compared between groups by using 
2 or Fisher exact tests for categoric data and unpaired t tests for continuous variables. All statistical analyses were performed with SASS 9.0 software (SASS Inc, Chicago, Ill). Postoperative outcomes were defined according to the guidelines for reporting morbidity and mortality after cardiac valvular operations. 13
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Results |
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TopAbstractIntroductionMethodsResultsDiscussionPost-IRAAF esophageal injury: A...ConclusionsReferences |
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Patient 1 had a fever and increased white blood cell count on the third postoperative day. He underwent multiple investigations, including echocardiography and computed tomography (CT) of the chest, without any abnormalities detected. Empiric antibiotic therapy was instituted, and the fever and leukocytosis abated. On postoperative day 10, the patient had symptoms suggestive of a transient ischemic attack after food intake. His neurologic symptoms completely resolved within 3 hours, but on the following day, more severe postprandial neurologic symptoms occurred. It was postulated that the patient was embolizing air into the left atrium during swallowing, and it was therefore decided to perform an exploratory thoracotomy. After median sternotomy, the left atrium was exposed, and a fistula was detected between the left atrium and esophagus. Portions of the left atrial free wall were obviously hemorrhagic and necrotic. The patient was placed on cardiopulmonary bypass, and the necrotic atrium was excised and replaced with a bovine pericardial patch. The esophagus showed severe necrosis and destruction at its contact site with the left atrium. The necrotic portions of the esophagus were resected, the proximal and distal esophageal stumps were closed, and a feeding gastrostomy tube was inserted. Four days later, the patient had a pneumomediastinum. The patient underwent a posterolateral thoracotomy, and a new fistula was detected between the proximal esophageal stump and the right main bronchus. The proximal esophagus was resected, and a right pneumonectomy was performed. The patient underwent uneventful gastroesophageal reconstruction 6 weeks later.
The postoperative course for patient 2 was uneventful until hematemesis developed 6 days after IRAAF. A tentative diagnosis of upper gastrointestinal bleeding was made, and a gastroscopy was performed. Unfortunately, the gastroscopy procedure was complicated by severe multiorgan air embolism, and the patient died 4 hours later. Pathologic examination revealed subacute esophageal injury and a fistula to the left atrium.
In patient 3 the early postoperative course was completely uneventful, and he was discharged to a cardiac rehabilitation center 9 days after the operation. On postoperative day 12, the patient had fever and neurologic symptoms, and he was referred back to our hospital. A CT scan of the chest with water-soluble contrast revealed evidence of esophageal injury, including contrast medium and free air in the mediastinum between the esophagus and left atrium (Figure 1). A posterolateral thoractomy was performed, and the necrotic esophagus was resected. However, as in patient 1, the patient had signs of a new esophageal perforation 6 days later, and therefore a more extensive esophageal resection was performed. Pathologic examination of the resected esophagus showed typical signs of thermal injury (Figure 2). Four weeks later, the patient underwent successful gastroesophageal reconstruction.
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionPost-IRAAF esophageal injury: A...ConclusionsReferences |
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2,3,6 Because of our initial successes with IRAAF in patients undergoing combined procedures, 14 we started to perform it as an isolated procedure by using minimally invasive techniques in 1998. To the best of our knowledge, the current study represents the largest reported patient cohort treated with IRAAF thus far. As with many novel treatment strategies, new types of complications might appear as more experience is gained. We believe it is important to communicate these new complications to the medical community so that other investigators monitor for their development in their own patient populations and try to develop methods of preventing their occurrence. 15 This might be of particular importance for IRAAF because a rapidly increasing number of institutions have started to perform this procedure worldwide. Furthermore, our report might also affect the practice of percutaneous catheter-based radiofrequency ablation, a procedure that is being performed by interventional electrophysiologists in rapidly increasing numbers. 1,5
Esophageal perforation occurred in 4 (1%) of 387 patients in the current study and was first reported by our group as a possible complication of IRAAF in 2002. 4 When the first esophageal injury occurred, we believed it was secondary to transesophageal echocardiography, a well-described but rare complication of this procedure. 16 We therefore stopped performing transesophageal echocardiography intraoperatively or in the immediate postoperative period in patients undergoing IRAAF. Because we were unsure of the exact mode of injury, however, we also modified the IRAAF procedure by moving the lesion line between the upper pulmonary veins to a more superior location in the left atrium. No esophageal injury was observed in the subsequent 110 patients. The second and third esophageal complications of our series occurred in the same week (IRAAF procedure numbers 154 and 158). Pathologic microscopic evaluation of the resected esophagus supplied evidence for direct thermal injury of the tissue. To avoid this complication in future procedures, we started placing a dry surgical sponge into the oblique sinus between the posterior left atrial wall and the esophagus. No esophageal injury was subsequently observed in the next 121 patients. However, a fourth esophageal perforation occurred in IRAAF patient 381. It should be noted that this fourth patient had undergone prior partial gastric resection for bleeding ulcers and therefore might have had an unusual anatomic position of the esophagus.
We were unable to detect any significant differences between patients with and without esophageal injury, including preoperative (Table 1
) and intraoperative (Tables 2 and 3) variables. In the case report by Gillinov and coworkers, 9 the authors concluded that the extremely small body size of their patient partially contributed to the IRAAF-induced esophageal perforation. However, we did not find any differences in patient weight or body mass index between groups. Although mean IRAAF probe temperatures and total energy levels might have been slightly higher in patients with esophageal complications (Table 3), they were within the range of patients without esophageal injury. We were also unable to identify any noteworthy findings in the operative notes of patients who subsequently had esophageal complications. It is possible that differences in the distance between the esophagus and posterior left atrium might have contributed on the occurrence of esophageal injury, but we did not measure this variable. Furthermore, such measurements are difficult to obtain and might therefore have limited clinical utility. Although the number of patients with esophageal perforation in the current study was small, it is troubling that we were unable to identify any reliable predictors of this life-threatening injury.
Histologic studies obtained in patients 3 and 4 revealed that the mechanism of esophageal injury was thermal in nature. It has been previously shown that intestinal tissue is far more susceptible to radiofrequency-induced thermal injury than muscle tissue. 17 Convection of heat generated at the interface between the ablation probe and left atrial tissue presumably resulted in a significant temperature increase and subsequent damage of adjacent esophageal tissue. This might explain why esophageal injury occurred even though the esophagus was not in direct contact with the ablation probe. Each patient with esophageal injury presented several days after IRAAF, after an initially unremarkable postoperative course, suggesting that the perforation did not occur acutely in the operating room. It is likely that intraoperative thermal damage induced an inflammatory reaction that subsequently led to secondary perforation several days thereafter.
Our experiences with esophageal injury after IRAAF have led to some important conclusions regarding diagnosis and therapy for this particular complication. All 4 patients in our series had moderately increased temperatures, white blood cell counts, and C-reactive protein levels after IRAAF, but unfortunately, these are nonspecific postoperative findings. In patients 1 and 3 the first clinical sign of esophageal perforation was a sudden neurologic deficit similar to a transient ischemic attack. Cranial CT shortly thereafter did not reveal any abnormalities, probably because small cerebral air emboli are usually not detectable by means of CT. The first clinical sign of perforation in patient 2 was hematemesis, leading to a diagnostic gastroscopy being performed for suspected gastrointestinal bleeding. Unfortunately, CO2 insufflation during the procedure led to massive embolization, resulting in severe neurologic injury and death. Our experiences have led us to recommend that a high degree of suspicion for esophageal injury be present after IRAAF, particularly in patients who have any neurologic signs or symptoms. We also strongly recommend that the first diagnostic procedure be CT of the chest or gastrograffin swallow, and gastroscopy should be strictly avoided. Indeed, any diagnostic procedure carrying a risk of air insufflation into the esophagus should be avoided in these patients. When the diagnosis of esophageal perforation has been confirmed, we recommend immediate surgical treatment with wide resection of the affected portion of the esophagus, followed by gastroesophageal reconstruction several weeks later.
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Post-IRAAF esophageal injury: A "Leipzig problem"? |
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TopAbstractIntroductionMethodsResultsDiscussionPost-IRAAF esophageal injury: A...ConclusionsReferences |
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9 by using a conventional surgical approach and different radiofrequency ablation equipment (Cobra RF; Boston Scientific, Boston, Mass). These authors also used a different pattern of left atrial lesion lines. In addition, personal communications with surgeons from other centers have revealed at least 4 other post-IRAAF esophageal perforations that have occurred in Germany alone. All 4 of these patients underwent operations through a median sternotomy, and ablation was performed with different radiofrequency systems, including one case that occurred after ablation with a microwave system. Three of the 4 patients subsequently died. We also know of at least one patient who died of sudden massive stroke 1 week after IRAAF. Esophageal perforation might have been the causative factor in this patient and should always be suspected in patients who have sudden neurologic deficits after IRAAF. |
Conclusions |
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TopAbstractIntroductionMethodsResultsDiscussionPost-IRAAF esophageal injury: A...ConclusionsReferences |
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Although intraoperative ablation has proven to be highly effective in curing patients from atrial fibrillation, we believe the risk of esophageal injury is too high and have therefore stopped performing this procedure at the Leipzig Heart Center. Our findings might also have significant implications for catheter-based radiofrequency ablation procedures. Further research is required to develop safer ablation technology. Potential areas of assessment include different modes of radiofrequency application (eg, bipolar energy application) or different energy sources for ablation (eg, cryoablation and laser ablation). Until safer methods of radiofrequency ablation are developed, we currently recommend against the use of this technique in patients undergoing cardiac surgery.
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References |
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TopAbstractIntroductionMethodsResultsDiscussionPost-IRAAF esophageal injury: A...ConclusionsReferences |
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C. Pappone, H. Oral, V. Santinelli, G. Vicedomini, C. C. Lang, F. Manguso, L. Torracca, S. Benussi, O. Alfieri, R. Hong, et al. Atrio-Esophageal Fistula as a Complication of Percutaneous Transcatheter Ablation of Atrial Fibrillation Circulation, June 8, 2004; 109(22): 2724 - 2726. [Abstract] [Full Text] [PDF]
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K. Khargi, A. Laczkovics, K. Muller, and T. Deneke A possible surgical technique to avoid esophageal and circumflex artery injuries using radiofrequency ablation to treat atrial fibrillation Interactive CardioVascular and Thoracic Surgery, June 1, 2004; 3(2): 352 - 355. [Abstract] [Full Text] [PDF]
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C. J. Brinster, S. Singhal, L. Lee, M. B. Marshall, L. R. Kaiser, and J. C. Kucharczuk Evolving options in the management of esophageal perforation Ann. Thorac. Surg., April 1, 2004; 77(4): 1475 - 1483. [Abstract] [Full Text] [PDF]
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A. Laczkovics, K. Khargi, and T. Deneke Esophageal perforation during left atrial radiofrequency ablation J. Thorac. Cardiovasc. Surg., December 1, 2003; 126(6): 2119 - 2120. [Full Text] [PDF]
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N. Doll, F. W. Mohr, and M. A. Borger Reply to the Editor J. Thorac. Cardiovasc. Surg., December 1, 2003; 126(6): 2120 - 2120. [Full Text] [PDF]
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A. M. Gillinov, P. M. McCarthy, G. Pettersson, B. W. Lytle, and T. W. Rice Esophageal perforation during left atrial radiofrequency ablation: is the risk too high? J. Thorac. Cardiovasc. Surg., November 1, 2003; 126(5): 1661 - 1662. [Full Text] [PDF]
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B. Sonmez, E. Demirsoy, and O. Yilmaz Atrioesophageal fistula: is it an unavoidable complication of radiofrequency ablation? J. Thorac. Cardiovasc. Surg., November 1, 2003; 126(5): 1662 - 1663. [Full Text] [PDF]
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