Esophageal Management 

Esophageal Management is a three legged stool that supports appropriate ablation techniques.

It includes: Accurate Esophageal Visualization, Reliable Temperature Monitoring and Esophageal Deflection.

Accurate Esophageal Visulalization

Which new techniques provide more accurate identification of esophageal location relative to the left atrium and ablation catheter when using Fluoro and/or ICE? These may be used with or without defelction

Esophageal Management Stool Image

Reliable Temperature Monitoring:

What are the most important characterisitics of a Temp Probe, and which type is best? How to know its position within the esophagus and its distance from the ablation catheter. Use with or without deflection. 

Esophageal Deflection:

How to safely increase the distance between the left atrium and the esophagus to minimize heating and potential injury. 

The Many Challenges of Esophageal and Vagal Nerve Injury Post LACA

  • “Fear of esophageal injury frequently results in modifications to the AF ablation lesion set that  may negatively affect the long-term clinical success of the ablation procedure.” (2, 26) 

  • Atrial esophageal fistula frequency have a variety of reported incidences.  One estimate is <0.1% to 0.25% of AF ablation procedures (20).   Underreporting is acknowledged to be a problem due to patients often traveling long distances for their procedures, delays in occurrence up to 59 days post procedure and the cause of death being attributed to other pathologies-Stroke, Sepsis, MI, etc.  

  • Much more common, but less acknowledged, is injury to the anterior vagusnerve and vagal nerve plexus during AF ablation (32).  This resulted in upper GI dysfunction through a 3 month follow up in 33% of the patients in one study (17).  

  • Whereas increased operator experience is associated with lower overall complications,the occurrence of AEF seems to be independent of operator case load. (21)

  • Atrial Esophageal Fistula can result from all modalities of ablations. (21, 28, 29)

  • Ablation catheter techniques that adjust power, duration, contact force and irrigation flow are being utilized, but the optimal combination of these factors, relative to obtaining full thickness lesions and a positive outcome without complications, remains unclear. (23)  Complicating these factors further is the variability of tissue type, thickness and distance between the LA and the esophagus. (7)
     

Esophageal Management Index

  • Esophageal anatomy and physiology.  Pg.  4-15

  • Anatomical variables that influence deflection.  Pg.  16-21

  • Factors related to ablation lesions efficacy and safety.  Pg. 22

  • Accurate esophageal visualization using ICE & fluoroscopy.  Pg. 23-39

  • Addressing the faults of temperature monitoring.  Pg. 40-48

  • EsoSure characteristics, insertion and positioning.  Pg. 49-82

  • Temperature Probe coordination with deflection.  Pg. 83-86

  • References.  Pg. 87-94

Click here for a PDF of the full Esophageal Management document.  

* Material contained in this document is copyrighted by Steven W. Miller, RN.  2018.  Use by commercial entities without written permission is prohibited.  

 

 

 

 

 

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