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J Thorac Cardiovasc Surg 2003;126:2119-2120
© 2003 The American Association for Thoracic Surgery
Letter to the editor |
Department of Cardiothoracic Surgery and Cardiology, University Hospital Bergmannsheil Bochum, Bochum, Germany
To the Editor:
Doll and colleagues1 reported an esophageal perforation incidence of 1% (4/387) after left atrial ablation with intraoperative radiofrequency ablation for atrial fibrillation. Risk factors could not be identified; therefore, they recommended against the use of intraoperative radiofrequency ablation for atrial fibrillation. In our opinion, however, a combination of various factors—such the device, the handling of device, the application time, the lesion pattern, and the surgical access—contribute to this complication, rather than the mere use of radiofrequency.
Doll and colleagues1 used temperature-controlled radiofrequency ablation with a 10-mm T-shaped rigid ablation probe (Radios 504; Osypka GmbH, Grenzach, Wyhlen, Germany) targeting a temperature of 60°C for 20 seconds for each lesion without taking the variability of the local atrial wall thickness into account. This catheter has a temperature overshoot, which proved to be a concern in terms of safety and rapidity of feedback control. Excessive tissue temperature could result in necrotic perforation.2 It is the overlap between two linear ablation lines where excessive tissue heating can occur. The Leipzig group did not mention this in their publication. The Leipzig group performed these procedures through a right lateral minithoracotomy; therefore, dissection of the doom of the left atrium was probably not done. Thus the relation ship between the left atrium and the esophagus was intense.
Several surgical centers have used temperature-controlled radiofrequency without reporting any esophageal or circumflex arterial injuries (Table 1). However, differences in technique can be distinguished. All centers used a standard sternotomy. Williams and coworkers4 used a flexible ablation probe with seven consecutive electrodes (Cobra; Boston Scientific–EP Technologies, La Garenne Colombes, France), each independently regulated by the generator targeting an even higher temperature (70°C-80°C) and longer application time (1 minute) per lesion than used by Doll and colleagues.1 Energy delivery was flexible but still up to 150 W. Ablation lesions were either made as separate ovals around the left and right orifices or as a complete circumferential island around all four pulmonary orifices. Nevertheless, Williams and coworkers4 did not report any injury, nor did Benussi and associates5 and Melo and colleagues,6 who also used temperature-controlled radiofrequency in a combined cohort of 105 patients.
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We therefore believe that the cause of the reported complication was the use of a rigid T-shaped temperature-controlled radiofrequency ablation probe pressed against the atrial wall, which was not dissected from the adjacent cardiac structures, with preset power and application time irrespective of the atrial wall thickness, especially when overlapping ablation lines were created. The mere use of radiofrequency was not responsible.
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