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Computed tomographic analysis of the esophagus, left atrium, and pulmonary veins: implications for catheter ablation of atrial fibrillation

  • Sung-Won Jang
  • Beom-June Kwon
  • Min-Seok Choi
  • Dong-Bin Kim
  • Woo-Seung Shin
  • Eun Joo Cho
  • Ji-Hoon Kim
  • Yong-Seog Oh
  • Man-Young Lee
  • Tai-Ho Rho
  • Jae-Hyung Kim
  • Bae-Young LeeEmail author
  • Hyo-Lim Kim
  • Jung-Im Jung
  • Kyung-Sup Song
Article

Abstract

Purpose:

The aim of this study was to investigate the anatomic relationship around the left atrium (LA) and to provide clinical information to help avoid the risk of an atrio-esophageal fistula during atrial fibrillation (AF) ablation.

Methods:

The multidetector spiral computed tomography images of 77 male patients (mean age, 54 ± 9 years) with drug-refractory AF and 37 male control subjects (mean age, 50 ± 11 years) were analyzed. We measured the following variables: (1) distance between the ostia of the pulmonary veins (PVs) and the ipsilateral esophageal border, (2) presence of a pericardial fat pad around each PV, and (3) contact width/length and presence of a fat pad between the LA and the esophagus.

Results:

The distance between the esophagus and the ostia of right superior PV, right inferior PV (RIPV), left superior PV, and left inferior PV (LIPV) was 27.2 ± 9.4 mm, 22.9 ± 10.3 mm, 2.7 ± 9.4 mm, and 7.1 ± 8.8 mm, respectively. A fat pad between the esophagus and the superior PV was present in more than 90% of the subjects in both groups. However, the fat pad around inferior PV was present less frequently in the patients than in the control group (p = 0.011, RIPV; p < 0.001, LIPV). The average length of the LA–esophagus contact in the patients and the control group subjects was 26.2 ± 10.4 and 18.5 ± 5.1 mm, respectively (p < 0.001).

Conclusion:

Caution should be exercised when ablating the LIPV because the esophagus is located in close proximity to the left-sided PV and most of the inferior PVs in patients with AF are not covered with fat pads.

Keywords

Atrial fibrillation Computed tomography Pulmonary veins Esophagus Atrium 

References

  1. 1.
    Fuster, V., Ryden, L. E., Cannom, D. S., Crijns, H. J., Curtis, A. B., Ellenbogen, K. A., et al. (2006). ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation—executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation). Journal of the American College of Cardiology, 48(4), 854–906.PubMedCrossRefGoogle Scholar
  2. 2.
    Cappato, R., Calkins, H., Chen, S. A., Davies, W., Iesaka, Y., Kalman, J., et al. (2009). Prevalence and causes of fatal outcome in catheter ablation of atrial fibrillation. Journal of the American College of Cardiology, 53(19), 1798–1803.PubMedCrossRefGoogle Scholar
  3. 3.
    Ghia, K. K., Chugh, A., Good, E., Pelosi, F., Jongnarangsin, K., Bogun, F., et al. (2009). A nationwide survey on the prevalence of atrioesophageal fistula after left atrial radiofrequency catheter ablation. Journal of Interventional Cardiac Electrophysiology, 24(1), 33–36.PubMedCrossRefGoogle Scholar
  4. 4.
    Pappone, C., Oral, H., Santinelli, V., Vicedomini, G., Lang, C. C., Manguso, F., et al. (2004). Atrio-esophageal fistula as a complication of percutaneous transcatheter ablation of atrial fibrillation. Circulation, 109(22), 2724–2726.PubMedCrossRefGoogle Scholar
  5. 5.
    Scanavacca, M. I., D'Avila, A., Parga, J., & Sosa, E. (2004). Left atrial-esophageal fistula following radiofrequency catheter ablation of atrial fibrillation. Journal of Cardiovascular Electrophysiology, 15(8), 960–962.PubMedCrossRefGoogle Scholar
  6. 6.
    Cummings, J. E., Schweikert, R. A., Saliba, W. I., Burkhardt, J. D., Kilikaslan, F., Saad, E., et al. (2006). Brief communication: atrial-esophageal fistulas after radiofrequency ablation. Annals of Internal Medicine, 144(8), 572–574.PubMedGoogle Scholar
  7. 7.
    Han, J., Good, E., Morady, F., & Oral, H. (2004). Images in cardiovascular medicine. Esophageal migration during left atrial catheter ablation for atrial fibrillation. Circulation, 110(24), e528.PubMedCrossRefGoogle Scholar
  8. 8.
    Cummings, J. E., Schweikert, R. A., Saliba, W. I., Burkhardt, J. D., Brachmann, J., Gunther, J., et al. (2005). Assessment of temperature, proximity, and course of the esophagus during radiofrequency ablation within the left atrium. Circulation, 112(4), 459–464.PubMedCrossRefGoogle Scholar
  9. 9.
    Tsao, H. M., Wu, M. H., Higa, S., Lee, K. T., Tai, C. T., Hsu, N. W., et al. (2005). Anatomic relationship of the esophagus and left atrium: implication for catheter ablation of atrial fibrillation. Chest, 128(4), 2581–2587.PubMedCrossRefGoogle Scholar
  10. 10.
    Helms, A., West, J. J., Patel, A., Mounsey, J. P., DiMarco, J. P., Mangrum, J. M., et al. (2009). Real-time rotational ICE imaging of the relationship of the ablation catheter tip and the esophagus during atrial fibrillation ablation. Journal of Cardiovascular Electrophysiology, 20(2), 130–137.PubMedCrossRefGoogle Scholar
  11. 11.
    Gilcrease, G. W., & Stein, J. B. (2010). A delayed case of fatal atrioesophageal fistula following radiofrequency ablation for atrial fibrillation. Journal of Cardiovascular Electrophysiology, 21(6), 708–711.PubMedCrossRefGoogle Scholar
  12. 12.
    Lemola, K., Sneider, M., Desjardins, B., Case, I., Han, J., Good, E., et al. (2004). Computed tomographic analysis of the anatomy of the left atrium and the esophagus: implications for left atrial catheter ablation. Circulation, 110(24), 3655–3660.PubMedCrossRefGoogle Scholar
  13. 13.
    Monnig, G., Wessling, J., Juergens, K. U., Milberg, P., Ribbing, M., Fischbach, R., et al. (2005). Further evidence of a close anatomical relation between the oesophagus and pulmonary veins. Europace, 7(6), 540–545.PubMedCrossRefGoogle Scholar
  14. 14.
    Chugh, A., Rubenstein, J., Good, E., Ebinger, M., Jongnarangsin, K., Fortino, J., et al. (2009). Mechanical displacement of the esophagus in patients undergoing left atrial ablation of atrial fibrillation. Heart Rhythm, 6(3), 319–322.PubMedCrossRefGoogle Scholar
  15. 15.
    Singh, S. M., d’Avila, A., Doshi, S. K., Brugge, W. R., Bedford, R. A., Mela, T., et al. (2008). Esophageal injury and temperature monitoring during atrial fibrillation ablation. Circulation. Arrhythmia and Electrophysiology, 1(3), 162–168.PubMedCrossRefGoogle Scholar
  16. 16.
    Tsuchiya, T., Ashikaga, K., Nakagawa, S., Hayashida, K., & Kugimiya, H. (2007). Atrial fibrillation ablation with esophageal cooling with a cooled water-irrigated intraesophageal balloon: a pilot study. Journal of Cardiovascular Electrophysiology, 18(2), 145–150.PubMedCrossRefGoogle Scholar
  17. 17.
    Buch, E., Nakahara, S., & Shivkumar, K. (2008). Intra-pericardial balloon retraction of the left atrium: a novel method to prevent esophageal injury during catheter ablation. Heart Rhythm, 5(10), 1473–1475.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Sung-Won Jang
    • 1
  • Beom-June Kwon
    • 1
  • Min-Seok Choi
    • 1
  • Dong-Bin Kim
    • 1
  • Woo-Seung Shin
    • 1
  • Eun Joo Cho
    • 1
  • Ji-Hoon Kim
    • 1
  • Yong-Seog Oh
    • 1
  • Man-Young Lee
    • 1
  • Tai-Ho Rho
    • 1
  • Jae-Hyung Kim
    • 1
  • Bae-Young Lee
    • 2
    • 3
    Email author
  • Hyo-Lim Kim
    • 2
  • Jung-Im Jung
    • 2
  • Kyung-Sup Song
    • 2
  1. 1.Division of Cardiology, Department of Internal MedicineThe Catholic University of Korea College of MedicineSeoulSouth Korea
  2. 2.Department of RadiologyThe Catholic University of Korea College of MedicineSeoulSouth Korea
  3. 3.Department of RadiologyThe Catholic University of Korea St. Paul’s HospitalDongdaemun-GuRepublic of Korea

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