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To the Editor— Contact force–sensing catheters and increased risk of atrioesophageal fistula: Is the tool to blame or the workmen?

Published:September 13, 2017DOI:https://doi.org/10.1016/j.hrthm.2017.09.020
      We read with great interest the article by Black-Maier et al
      • Black-Maier E.
      • Pokorney S.D.
      • Barnett A.S.
      • Zeitler E.P.
      • Sun A.Y.
      • Jackson K.P.
      • Bahnson T.D.
      • Daubert J.P.
      • Piccini J.P.
      Risk of atrioesophageal fistula formation with contact force-sensing catheters.
      suggesting a significant increase in the risk of atrioesophageal fistula formation with the use of contact force (CF)–sensing catheters. While the authors allude to the possibility that operators using CF catheters “may ablate longer and with greater force than those using traditional catheters,” we would go further by suggesting that widespread use of a force-time integral (FTI) target value of 400 gs may have contributed to this issue. This “one size fits all” value was derived from the EFFICAS I study
      • Neuzil P.
      • Reddy V.Y.
      • Kautzner J.
      • Petru J.
      • Wichterle D.
      • Shah D.
      • Lambert H.
      • Yulzari A.
      • Wissner E.
      • Kuck K.H.
      Electrical reconnection after pulmonary vein isolation is contingent on contact force during initial treatment: results from the EFFICAS I study.
      published in 2013, before Food and Drug Administration approval of CF catheters. However, it is well known that there is a significant variation in wall thickness in different regions of the left atrium. In our own study
      • Das M.
      • Loveday J.J.
      • Wynn G.J.
      • Gomes S.
      • Saeed Y.
      • Bonnett L.J.
      • Waktare J.E.P.
      • Todd D.M.
      • Hall M.C.S.
      • Snowdon R.L.
      • Modi S.
      • Gupta D.
      Ablation index, a novel marker of ablation lesion quality: prediction of pulmonary vein reconnection at repeat electrophysiology study and regional differences in target values.
      of late reconnection after atrial fibrillation ablation, we demonstrated that an FTI value of 420 gs was needed to avoid late reconnection in anterior/roof segments of the pulmonary vein isolation circle, but only 230 gs was required for posterior/inferior segments. An FTI target of 400 gs on the posterior wall therefore appears markedly excessive.
      We therefore suspect that this increased rate of atrioesophageal fistulas observed by Black-Maier et al may be more related to how CF catheters have been used to achieve lesion target values rather than to the CF information provided by the catheters themselves. In our opinion, CF catheters remain useful tools, but it is up to operators to learn how to use them effectively.

      References

        • Black-Maier E.
        • Pokorney S.D.
        • Barnett A.S.
        • Zeitler E.P.
        • Sun A.Y.
        • Jackson K.P.
        • Bahnson T.D.
        • Daubert J.P.
        • Piccini J.P.
        Risk of atrioesophageal fistula formation with contact force-sensing catheters.
        Heart Rhythm. 2017; 14: 1328-1333
        • Neuzil P.
        • Reddy V.Y.
        • Kautzner J.
        • Petru J.
        • Wichterle D.
        • Shah D.
        • Lambert H.
        • Yulzari A.
        • Wissner E.
        • Kuck K.H.
        Electrical reconnection after pulmonary vein isolation is contingent on contact force during initial treatment: results from the EFFICAS I study.
        Circ Arrhythm Electrophysiol. 2013; 6: 327-333
        • Das M.
        • Loveday J.J.
        • Wynn G.J.
        • Gomes S.
        • Saeed Y.
        • Bonnett L.J.
        • Waktare J.E.P.
        • Todd D.M.
        • Hall M.C.S.
        • Snowdon R.L.
        • Modi S.
        • Gupta D.
        Ablation index, a novel marker of ablation lesion quality: prediction of pulmonary vein reconnection at repeat electrophysiology study and regional differences in target values.
        Europace. 2017; 19: 775-783

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