Advertisement

Gastric hypomotility after second-generation cryoballoon ablation—Unrecognized silent nerve injury after cryoballoon ablation

      Background

      Few data are available on gastric hypomotility (GH) after cryoballoon pulmonary vein isolation. Also, the use of esophageal temperature monitoring for the prevention of endoscopically detected esophageal lesions (EDELs) is not well established.

      Objective

      The purpose of this study was to investigate GH and the impact of an esophageal probe on EDELs during second-generation cryoballoon ablation.

      Methods

      One hundred four patients with paroxysmal atrial fibrillation undergoing second-generation cryoballoon ablation under conscious sedation followed by esophagogastroscopy were prospectively included. Temperature probes were used in the first 40 (38.5%) patients, but not in the latter 64 (61.5%). Pulmonary vein isolation was performed with one 28-mm balloon using single 3-minute freeze techniques.

      Results

      Clinical and procedural characteristics were similar between the groups. Esophagogastroscopy 1.4 ± 0.5 days postablation demonstrated GH and EDELs in 18 (17.3%) and 9 (8.7%) patients. The incidence of GH was similar (7 of 40 vs 11 of 64; P = .967) between the groups, while that of EDELs was significantly higher in the former than in the latter group (8 of 40 vs 1 of 64; P < .0001). In multivariate analyses, the esophagus-right inferior pulmonary vein ostium distance (hazard ratio 0.870; 95% confidence interval 0.798–0.948; P = .002) was the sole predictor of GH, and the optimal cutoff for the prediction was 18.2 mm (sensitivity 88.1%; specificity 77.8%). The use of esophageal probes was the sole predictor of EDELs (hazard ratio 15.750; 95% confidence interval 1.887–131.471; P = .011). All collateral damage was asymptomatic and healed on repeat esophagogastroscopy at a mean of 2 ± 1 months postprocedure.

      Conclusion

      Second-generation cryoballoon ablation is associated with an increased incidence of silent periesophageal nerve injury even using short freeze times, and anatomical information aids identifying high-risk populations. The use of esophageal probes increases the risk of EDELs.

      Keywords

      To read this article in full you will need to make a payment
      Subscribe to Heart Rhythm
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Calkins H.
        • Kuck K.H.
        • Cappato R.
        • et al.
        2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design: a report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation.
        Heart Rhythm. 2012; 9: 632-696
        • Nault I.
        • Miyazaki S.
        • Forclaz A.
        • Wright M.
        • Jadidi A.
        • Jaïs P.
        • Hocini M.
        • Haïssaguerre M.
        Drugs vs. ablation for the treatment of atrial fibrillation: the evidence supporting catheter ablation.
        Eur Heart J. 2010; 31: 1046-1054
        • Müller P.
        • Dietrich J.W.
        • Halbfass P.
        • Abouarab A.
        • Fochler F.
        • Szöllösi A.
        • Nentwich K.
        • Roos M.
        • Krug J.
        • Schade A.
        • Mügge A.
        • Deneke T.
        Higher incidence of esophageal lesions after ablation of atrial fibrillation related to the use of esophageal temperature probes.
        Heart Rhythm. 2015; 12: 1464-1469
        • Deneke T.
        • Bünz K.
        • Bastian A.
        • Päsler M.
        • Anders H.
        • Lehmann R.
        • Meuser W.
        • deGroot J.R.
        • Horlitz M.
        • Haberkorn R.
        • Mügge A.
        • Shin D.I.
        Utility of esophageal temperature monitoring during pulmonary vein isolation for atrial fibrillation using duty-cycled phased radiofrequency ablation.
        J Cardiovasc Electrophysiol. 2011; 3: 255-261
        • Shah D.
        • Dumonceau J.M.
        • Burri H.
        • Sunthorn H.
        • Schroft A.
        • Gentil-Baron P.
        • Yokoyama Y.
        • Takahashi A.
        Acute pyloric spasm and gastric hypomotility: an extracardiac adverse effect of percutaneous radiofrequency ablation for atrial fibrillation.
        J Am Coll Cardiol. 2005; 46: 327-330
        • Kuwahara T.
        • Takahashi A.
        • Takahashi Y.
        • et al.
        Clinical characteristics and management of periesophageal vagal nerve injury complicating left atrial ablation of atrial fibrillation: lessons from eleven cases.
        J Cardiovasc Electrophysiol. 2013; 24: 847-851
        • Miyazaki S.
        • Taniguchi H.
        • Kusa S.
        • Komatsu Y.
        • Ichihara N.
        • Takagi T.
        • Iwasawa J.
        • Kuroi A.
        • Nakamura H.
        • Hachiya H.
        • Hirao K.
        • Iesaka Y.
        Factors associated with periesophageal vagal nerve injury after pulmonary vein antrum isolation.
        J Am Heart Assoc. 2014; 3: e001209
        • Parkman H.P.
        • Hasler W.L.
        • Fisher R.S.
        American Gastroenterological Association. American Gastroenterological Association technical review on the diagnosis and treatment of gastroparesis.
        Gastroenterology. 2004; 127: 1592-1622
        • Gaita F.
        • Caponi D.
        • Pianelli M.
        • Scaglione M.
        • Toso E.
        • Cesarani F.
        • Boffano C.
        • Gandini G.
        • Valentini M.C.
        • De Ponti R.
        • Halimi F.
        • Leclercq J.F.
        Radiofrequency catheter ablation of atrial fibrillation: a cause of silent thromboembolism? Magnetic resonance imaging assessment of cerebral thromboembolism in patients undergoing ablation of atrial fibrillation.
        Circulation. 2010; 122: 1667-1673
        • Kojodjojo P.
        • O’Neill M.D.
        • Lim P.B.
        • et al.
        Pulmonary venous isolation by antral ablation with a large cryoballoon for treatment of paroxysmal and persistent atrial fibrillation: medium-term outcomes and non-randomised comparison with pulmonary venous isolation by radiofrequency ablation.
        Heart. 2010; 96: 1379-1384
        • Coulombe N.
        • Paulin J.
        • Su W.
        Improved in vivo performance of second-generation cryoballoon for pulmonary vein isolation.
        J Cardiovasc Electrophysiol. 2013; 24: 919-925
        • Su W.
        • Kowal R.
        • Kowalski M.
        • Metzner A.
        • Svinarich J.T.
        • Wheelan K.
        • Wang P.
        Best practice guide for cryoballoon ablation in atrial fibrillation: the compilation experience of more than 3000 procedures.
        Heart Rhythm. 2015; 12: 1658-1666
        • Fürnkranz A.
        • Bordignon S.
        • Böhmig M.
        • Konstantinou A.
        • Dugo D.
        • Perrotta L.
        • Klopffleisch T.
        • Nowak B.
        • Dignaß A.U.
        • Schmidt B.
        • Chun J.K.
        Reduced incidence of esophageal lesions by luminal esophageal temperature-guided second-generation cryoballoon ablation.
        Heart Rhythm. 2015; 12: 268-274
        • Miyazaki S.
        • Nakamura H.
        • Taniguchi H.
        • Takagi T.
        • Iwasawa J.
        • Watanabe T.
        • Hachiya H.
        • Hirao K.
        • Iesaka Y.
        Esophagus related complications during second-generation cryoballoon ablation—insight from simultaneous esophageal temperature monitoring from two esophageal probes.
        J Cardiovasc Electrophysiol. 2016; 27: 1038-1044
        • Sacher F.
        • Monahan K.H.
        • Thomas S.P.
        • et al.
        Phrenic nerve injury after atrial fibrillation catheter ablation: characterization and outcome in a multicenter study.
        J Am Coll Cardiol. 2006; 47: 2498-2503
        • Sánchez-Quintana D.
        • Cabrera J.A.
        • Climent V.
        • Farré J.
        • Mendonça M.C.
        • Ho S.Y.
        Anatomic relations between the esophagus and left atrium and relevance for ablation of atrial fibrillation.
        Circulation. 2005; 112: 1400-1405
        • Ho S.Y.
        • Cabrera J.A.
        • Sanchez-Quintana D.
        Vagaries of the vagus nerve: relevance to ablationists.
        J Cardiovasc Electrophysiol. 2006; 17: 330-331
        • Kuwahara T.
        • Takahashi A.
        • Okubo K.
        • et al.
        Oesophageal cooling with ice water does not reduce the incidence of oesophageal lesions complicating catheter ablation of atrial fibrillation: randomized controlled study.
        Europace. 2014; 16: 834-839
        • Guiot A.
        • Savouré A.
        • Godin B.
        • Anselme F.
        Collateral nervous damages after cryoballoon pulmonary vein isolation.
        J Cardiovasc Electrophysiol. 2012; 23: 346-351
        • Goff R.P.
        • Bersie S.M.
        • Iaizzo P.A.
        In vitro assessment of induced phrenic nerve cryothermal injury.
        Heart Rhythm. 2014; 11 (1779–1184)
        • Avitall B.
        • Kalinski A.
        Cryotherapy of cardiac arrhythmia: from basic science to the bedside.
        Heart Rhythm. 2015; 12: 2195-2203
        • Sternick E.B.
        • Persiano A.C.
        • Arantes V.
        Is it safe to monitor oesophageal temperature during AF ablation?.
        Europace. 2012; 10: 1432
        • Ahmed H.
        • Neuzil P.
        • d’Avila A.
        • Cha Y.M.
        • Laragy M.
        • Mares K.
        • Brugge W.R.
        • Forcione D.G.
        • Ruskin J.N.
        • Packer D.L.
        • Reddy V.Y.
        The esophageal effects of cryoenergy during cryoablation for atrial fibrillation.
        Heart Rhythm. 2009; 6: 962-969

      Linked Article

      • To the Editor— Esophageal thermal probes and esophageal lesions during cryoablation
        Heart RhythmVol. 14Issue 10
        • Preview
          May esophageal thermal probes (ETPs) produce esophageal thermal lesions (ETLs)? This question surfaced in the literature years ago, so far confined to radiofrequency ablation procedures. The article by Miyazaki et al1 is now exporting the subject to the framework of cryoablation. Its aim was to investigate the incidence of gastric hypomotility, but as a side result, the authors found that the occurrence of ETLs was higher in patients who had luminal esophageal temperature (LET) monitoring: 8 in the 40 monitored patients and only 1 in the 64 nonmonitored ones.
        • Full-Text
        • PDF