Real-time rotational ICE imaging of the relationship of the ablation catheter tip and the esophagus during atrial fibrillation ablation.

INTRODUCTION: Atrioesophageal fistula is a rare complication of atrial fibrillation (AF) ablation that should be avoided. We investigated whether rotational intracardiac echocardiography (ICE) can help to minimize ablation close to the esophagus. METHODS AND
RESULTS: We studied 41 patients referred for catheter ablation of refractory AF. A rotational ICE catheter was inserted into the (LA) to determine the location of the esophagus. The esophagus was identified to be either adjacent to the pulmonary vein (PV) ostium or to a cuff 2 cm outside the ostium. Circumferential ablation was performed at the PV ostium, with the exact ablation location determined by ICE. The relationship of the catheter tip to the esophagus was imaged during energy delivery, allowing interruption when respiration moved the tip closer to the esophagus. Out of 41 patients, the esophagus was seen near left-sided PVs in 32 and near right-sided PVs in three patients. The median distance from LA endocardium to esophagus was 2.2 mm (range, 1.4-6 mm). In 21 of 35 patients with a closely related esophagus, ablation over the esophagus was avoided by ablating either lateral or medial to the esophagus. In 14 patients, the esophagus could not be avoided, and risk was minimized by limiting lesion size. Significant movement (>10 mm) of the esophagus during the procedure occurred in 3/41 cases.
CONCLUSION: Rotational ICE can accurately determine the distance of ablation sites from the esophagus. Real-time imaging of the relationship of the ablation catheter tip to the esophagus may reduce the incidence of esophageal injury.