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In this 296th episode I welcome Dr. Mike Essandoh to do another master clinician episode. We discuss Dr. Essandoh’s tips for being successful clinically, in research, in leadership, in innovation and in technology.
CME: Link
Random Recs:
I am a big fan of your podcast, listen to EVERY episode. This episode left one with one confusing statement! The incidence of Left Atrial to Esophageal Fistula after ablation of AF with Radiofrequency Ablation is of the order of 0. 015-0.04 %! It’s very rare but almost always fatal when it’s recognized!
The podcast leaves one thinking it’s much much higher!
Dear Dr. Nayyar,
Thank you for listening to episode 296 of the ACCRAC podcast and sharing your insights and perspectives.
I wanted to provide some additional information regarding the podcast section that focused on the complications associated with thermal ablation of atrial fibrillation.
This discussion was prompted by a case report of a patient who developed an esophago-pericardial fistula following radiofrequency atrial fibrillation ablation. You are correct that the incidence of this specific complication is low; our research indicated an occurrence rate of 0.03-0.05%, which we published in the Journal of Cardiothoracic and Vascular Anesthesia Case Conference (see Reference #1).
However, thermal energy-related esophageal injury after atrial fibrillation ablation has a higher incidence, reported as high as 47%, according to the literature (Reference #2). The esophagus is located just 5 mm from the left atrium, increasing the risk of injury. Thermal ablation energy can cause minor esophageal mucosal ulcerations that are treatable with proton pump inhibitors, H2 receptor blockers, and sucralfate, or severe damage, including transmural injuries, perforations, and fistula formations with the pericardium or left atrium, which have a mortality rate of approximately 80% (Reference #1).
In our JCVA Case Conference article, we presented a classification system for the varying degrees of esophageal thermal injury to emphasize the importance of early diagnosis and treatment of Class III injuries to prevent complications such as fistulas or esophageal perforations that cause significant morbidity and mortality. From our FDA-approved investigational device exemption study published in JACC EP, we found that the rate of ablation-related esophageal thermal injury was 35% in the control arm compared to only 6% in the esophageal deviation group, and I referenced this specifically in the podcast (Reference #3).
Our mission at The Ohio State Wexner Medical Center was to develop a device that prevented esophageal thermal injury during atrial fibrillation ablation by deflecting the esophagus away from the ablation site to avoid the abovementioned complications and improve patient outcomes. I hope this response clarifies the spectrum of esophageal thermal injury potentially associated with atrial fibrillation ablation for ACCRAC listeners. Thank you for bringing this issue to my attention.
Dear Dr. Essandoh, I thank you for your response and I am impressed by the depth of your research on the topic. I was unaware of the such high incidence of thermal esophageal injuries. Thankyou very much for clarifying that.
I am a great fan of ACCRAC and of you, have listened to all episodes where you were invited to speak as an expert and now master clinician as I too have been practicing the craft of CV anesthesia for 26 yrs now. Took care of 1 such case of LA esophagus Fistula with a bad outcome. Not unexpectedly off course.
Thanks again.