Esophageal Thermal Injury Following Cryoballoon Ablation for Atrial Fibrillation

Abstract

Objectives: This study evaluated the rate and predictors of endoscopically detected esophageal thermal lesions (EDEL) in patients who underwent cryoballoon atrial fibrillation (AF) ablation (CBA). Background: EDEL is a known complication of catheter ablation for AF and is the inciting factor for atrial esophageal fistula formation. Methods: An observational study was conducted of patients with AF presenting for CBA. Pre-procedural magnetic resonance imaging was used to retrospectively evaluate the distance between the atrial endocardium and the esophageal lumen (AED). Intraprocedural esophageal luminal temperature and balloon temperatures were recorded. All patients underwent upper endoscopy (EGD) 24 h post-ablation. Clinical, anatomical, and ablation parameters were analyzed using logistic regression for association with thermal injury. Results: A total of 95 patients (37% women; 71% paroxysmal AF) were included in the study. Esophageal thermal injury was detected on EGD in 21 patients (22%). EDEL was mostly mild (20 of 21 patients) and severe in only 1 of 21 patients. Univariate logistic regression identified gastroesophageal reflux disease to be associated with increased risk of thermal injury (odds ratio [OR]: 3.2; 95% confidence interval [CI]: 1.00 to 10.46; p = 0.04), whereas a wider AED was protective (OR: 0.16; 95% CI: 0.05 to 0.515; p = 0.002). Esophageal wall thickness was also protective (OR: 0.04; 95% CI: 0.002 to 0.864; p = 0.04). In multivariate analysis, only AED (OR: 0.22; 95% CI: 0.06 to 0.77; p = 0.018) and obesity (OR: 4.63; 95% CI: 1.13 to 18.97; p = 0.033) were associated with EDEL. Esophageal luminal temperature, number, and duration of cryoballoon applications and balloon temperature were not predictors of EDEL. Conclusions: EDEL following CBA occurred in 22% of patients and was mostly mild. Obesity and atrioesophageal distance were independently associated with increased risk.