Introduction: Proactive esophageal cooling has been FDA cleared to reduce the likelihood of ablation-related esophageal injury resulting from radiofrequency (RF) cardiac ablation procedures. Data suggest that procedure times for RF pulmonary vein isolation (PVI) also decrease when proactive esophageal cooling is employed instead of luminal esophageal temperature (LET) monitoring. Reduced procedure times may allow increased electrophysiology (EP) lab throughput. We aimed to quantify the change in EP lab throughput of PVI cases after the introduction of proactive esophageal cooling. Methods: EP lab throughput data were obtained from three electrophysiology groups. We then compared EP lab throughput over equal time frames at each site before (pre-adoption) and after (post-adoption) the adoption of proactive esophageal cooling. Results: Over the time frame of the study, a total of 2,498 PVIs were performed over a combined 74 months, with cooling adopted in September 2021, November 2021 and March 2022 at each respective site. In the pre-adoption time frame, 1,026 PVIs were performed using a combination of LET monitoring with the addition of esophageal deviation when deemed necessary by the operator. In the post-adoption time frame, 1,472 PVIs were performed using exclusively proactive esophageal cooling, representing a mean 43% increase in throughput (p < 0.0001), despite the loss of two operators during the post-adoption time frame. Conclusion: Adoption of proactive esophageal cooling during PVI ablation procedures is associated with a significant increase in EP lab throughput, even after a reduction in total number of operating physicians in the post-adoption group.

Introduction: Post-ablation chest pain is a common occurrence in patients after radiofrequency (RF) pulmonary vein isolation (PVI) ablation for the treatment of atrial fibrillation (AF), with a reported incidence of up to 50%. Pain can be caused by pericarditis, vagal plexus thermal injury, gastroparesis, or local inflammation. Active esophageal cooling is FDA cleared for reducing the likelihood of ablation-related esophageal injury resulting from RF cardiac ablation procedures, but cooling has also been reported to have pleiotropic effects which may mitigate inflammation and reduce the likelihood of post-ablation chest pain. The aim of this study is to quantify the change in incidence of post-ablation chest pain after the adoption of active esophageal cooling during RF ablations. Methods: Data from a community hospital registry were obtained for the 12 months prior to (pre-adoption), and the 12 months after adoption (post-adoption) of active esophageal cooling in December 2021 during RF ablations. Type of ablation was recorded, along with patient’s age, post-ablation symptoms, and type of prophylactic treatment utilized. Incidence rates of chest pain before and after adoption of esophageal cooling were then compared. Results: Data were reviewed from 183 patients. In the pre-adoption cohort, patients were given 2 weeks of daily sucralfate and pantoprazole, with an additional 4 weeks in cases with persisting symptoms. In this group, 90 patients (66.7% persistent AF) with a mean age of 69.6 years (SD ± 10.34) received PVI, with 62 (68.9%) receiving roof lines, 60 (66.7%) receiving floor lines, and 41 (45.6%) reporting post-ablation chest pain requiring extension of treatment to 6 weeks. In the post-adoption cohort, 2 days of sucralfate and pantoprazole was given, and a total of 93 patients (75.2% persistent AF) with a mean age of 68.3 years (SD ± 10.28) received PVI, with 79 (84.5%) receiving roof lines, 75 (80.6%) receiving floor lines, and none reporting post-ablation chest pain (p<0.0001). Conclusion: Adoption of active esophageal cooling was associated with a significant reduction in post-ablation chest pain despite increased use of posterior wall isolation and decreased use of prophylactic treatment.

The excellent review by Houmsse and Daoud of techniques and methods utilized to protect the esophagus from injury during atrial fibrillation (AF) ablation appropriately concludes that considering the ease of use, minimal side effects, and low costs associated with esophageal protection devices, compelling evidence exists for use of esophageal protection as routine care for AF ablation. Some additional data are available which would warrant inclusion in further consideration of this topic. Three recent studies have demonstrated the inability of LET monitoring to protect the esophagus, whereas meta-analysis of three studies of manual cooling using direct liquid instillation suggests that this approach significantly reduced high-grade lesion formation (OR of 0.39, 95% CI 0.17 to 0.89). Moreover, three studies using a commercially available cooling device FDA cleared for thermal regulation have shown reductions in esophageal lesion severity without degradation in ablation efficacy.

We congratulate Kar et al. on their elegant study evaluating ex-vivo temperature profiles and the resulting thermal injury formation on the epiesophageal surface during radiofrequency (RF) ablation. In addition to being the first study to detail temperature profiles inclusive of the epiesophageal surface during RF ablation, we believe that the results add further concern to the use of temperature sensing technology in the quest to reduce esophageal injury. Three recent clinical trials have evaluated the efficacy of luminal esophageal temperature (LET) monitoring and found either no benefits, or signals of harm. On the other hand, two pilot RCTs suggest benefits of active cooling, and a large RCT, the IMPACT study, further confirms this benefit by finding an 83% reduction in esophageal lesion formation using an active cooling device. With no degradation in ablation efficacy, as well as a reduction/elimination of the need for fluoroscopy and reports of shortened procedure time with active cooling technology, the data of Kar et al., combined with growing clinical data, suggest that continued use of LET monitoring may be unjustified.

A document by Shailee Shah. Click on the document to view its contents.