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J Thorac Cardiovasc Surg 2003;126:1661-1662
© 2003 The American Association for Thoracic Surgery
Letters to the editor |
a The Center for Atrial Fibrillation, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
To the Editor:
The recent article by Doll and colleagues documents a 1% incidence of esophageal perforation with intraoperative radiofrequency ablation of atrial fibrillation (AF).1 This observation serves as an important word of caution as we increase the application of surgical ablation and design minimally invasive procedures to treat AF. In our exploration of new approaches to cure AF, we must first follow the edict "do no harm." Although AF is an undesirable and dangerous heart rhythm, we cannot justify major complications in its treatment.
The esophageal injuries described by Doll and colleagues resulted from the application of a heat-based energy source to the left atrial endocardium. In each case, the esophagus, which courses posterior to the left atrium, suffered a burn with resulting esophageal perforation. They note that this complication has occurred with unipolar radiofrequency and microwave energies.1,2 It is likely that collateral damage in general and esophageal injury in particular will occur occasionally with any heat-based, endocardial approach to AF ablation that lacks precise control of lesion depth and direction.
Safety in AF ablation requires that the depth of tissue injury be controlled during ablation; delivery of energy must be focused and directed to avoid collateral damage. In addition, however, it is generally accepted that efficacy requires transmural atrial lesions. There are several promising modalities that satisfy both of these criteria. Safety may be reliably achieved with bipolar or epicardial energy delivery. Bipolar radiofrequency devices ablate only the tissue between the jaws of the clamp, eliminating the risk of esophageal injury.3 Epicardial delivery of energy with a shielded, directional catheter is also an attractive option. Epicardial ablation using ultrasound energy may have particular advantages, as this energy source allows reliable creation of a lesion that is 10 mm in depth and design of the ultrasound catheter ensures directional delivery of energy from the epicardium to the endocardium.
As surgeons explore these technologies and devise new procedures to cure AF, we must follow the lead of the group from Leipzig and share our experiences, whether they be favorable or unfavorable. This strategy will facilitate development of effective and safe procedures to ablate AF. And this, in turn, will offer the possibility of AF ablation to large numbers of patients, including those with isolated or lone AF.
References
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  J. E. Cummings, R. A. Schweikert, W. I. Saliba, J. D. Burkhardt, J. Brachmann, J. Gunther, V. Schibgilla, A. Verma, M. Dery, J. L. Drago, et al. Assessment of Temperature, Proximity, and Course of the Esophagus During Radiofrequency Ablation Within the Left Atrium Circulation, July 26, 2005; 112(4): 459 - 464. [Abstract] [Full Text] [PDF]
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 T. A. Molloy Midterm Clinical Experience With Microwave Surgical Ablation of Atrial Fibrillation Ann. Thorac. Surg., June 1, 2005; 79(6): 2115 - 2118. [Abstract] [Full Text] [PDF]
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