Esophageal Dilatation Post – Gastric
Banding And Catheter Ablation For Atrial Fibrillation: A Case Report
Credits: Simon Townsend1, Andrew James2, Nicholas Daunt MBBS1, Karen P. Phillips MBBS1
1 Greenslopes Private Hospital, Brisbane, Australia, 2 St Jude Medical Australia Pty Ltd, Brisbane, Australia
Address for Correspondence: Dr Karen Phillips, Visiting Cardiac Electrophysiologist, Greenslopes Private Hospital, Suite 212, Ramsay Specialist Centre, Newdegate Street, Greenslopes, QLD, 4120, Australia.
injury is a potential serious complication of catheter ablation for atrial
fibrillation. We report a case of significant esophageal dilatation following
previous laparascopic gastric banding in a patient with permanent atrial
fibrillation undergoing a pulmonary vein isolation procedure.
Esophageal injury is a
potential serious complication of catheter ablation for atrial fibrillation
(AF). We report a case of significant esophageal dilatation following previous
laproscopic gastric banding (LGB) in a patient undergoing pulmonary vein
isolation (PVI) for atrial fibrillation.
A 53 year male with a 2 year
history of permanent atrial fibrillation and a prior history of laproscopic
gastric banding (LGB) for obesity underwent a pre-procedure planning cardiac CT
scan. Moderate esophageal dilatation was demonstrated on the cardiac CT with the
esophageal diameter reaching a maximum of 42mm level with the posterior left
atrial wall (Fig 1). A barium swallow showed normal esophageal
motility but with markedly slowed emptying times (Fig 2).
Figure 1: Postero-anterior (left) and cranial (right) views of 3- dimensional reconstruction of the left atrium and dilated esophagus from the preprocedural CT scan.
Figure 2: Barium swallow image showing moderate esophageal dilatation with pooling of barium proximal to the gastric band.
A catheter ablation procedure
was performed which included wide pulmonary vein antral electrical isolation
guided by a cardiac navigational system (Ensite, St Jude Medical) and intra-cardiac
The position of the esophagus
was delineated on the integrated CT navigational map and on fluoroscopy by
placement of an esophageal thermistor probe. Radiofrequency energy was
delivered through an open irrigated tip catheter and titrated to maximum 25W
and 40°C for lesions applied to the left atrial posterior
wall. Esophageal temperature rises were only seen in association with lesions
applied to the right inferior pulmonary vein and energy applications here were
limited to avoid esophageal temperatures >38.5°C.
At 6 months follow-up the
patient remains in sinus rhythm with no complications.
The potential for esophageal
injury following ablation on the posterior wall of the left atrium is well
recognized. The most severe complication is atrio-esophageal fistula formation,
with almost uniformly fatal outcomes .Peri-oesophageal
nerve damage is also described following catheter ablation for AF and may
result in gastric hypomotility .
Esophageal pathology may
increase the potential for injury during catheter ablation procedures for AF. A
case of a large esophageal diverticulum has been reported that was recognized
prior to a successful PVI, with the diverticulum identified via barium swallow
and tagged on the electroanatomic map . A documented case of esophageal
dilatation due to a massive hiatal hernia resulted in the catheter ablation
being abandoned due to the risk of potential esophageal injury .
To our knowledge this is the
first report of significant oesophageal dilatation in a patient with a prior history of LGB undergoing
catheter ablation for AF.
Esophageal dilatation post
LGB is relatively common with 14-17% of patients developing post-operative
dilatation within 6 to12 months . This is believed to
be due to the reduced gastric pouch and the band posing a higher resistance to
passing food. Other complications related to LGB placement that might impact left
atrial ablation include pouch formation due to nutritional overload and
inflammation or band slippage, all of which have similar effects in creating
herniation of the gastric pouch and possibly the esophagus .
A number of techniques have
been suggested to reduce the occurrence of esophageal injury during PVI. These
include limiting the duration and power of lesion application to the posterior
LA wall adjacent to the oesophagus . Intraprocedural
monitoring of the course of the esophagus in relation to the left atrium has
also been suggested and includes continuous ICE monitoring of esophagus
location , intraprocedural barium swallow and placement
of an oesophageal thermistor . Reliance on the anatomical
relationships from a preprocedural CT scan is
recognized as being less accurate as the range of esophageal motion during a
catheter ablation for AF has been shown to be greater than 2cm .
It is currently unclear what the impact of oesophageal pathology is on “added”
vulnerability to injury from cardiac radiofrequency energy application.
As obesity increases in
prevalence and the success and ease of weight reduction through LGB makes these
procedures more common, it is likely that patients with a history of prior LGB
will present increasingly for catheter ablation for AF . Cardiac
Electrophysiologists performing catheter ablation procedures for AF should have
a good level of awareness of the potential esophageal and gastric complications
following LGB. Additional precautions should be taken both to identify
potential pathology preprocedurally and also to actively reduce the potential
for esophageal injury during ablation.
Esophageal dilatation following
LGB is common and may increase the potential for esophageal injury during
catheter ablation for AF. Awareness of esophageal pathology in patients with a
history of LGB and appropriate procedure planning for catheter ablation may
prevent esophageal complications.
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