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oesophageal fistula is the other serious complication of catheter ablation
- oscar,m jolobe (12 April 2008)
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Surgical Ablation for Atrial Fibrillation : Combined Interventional Cardiology and Cardiac Surgical Programmes for Atrial Fibrillation
- Dr Su Sethi (19 April 2008)
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oscar,m jolobe, retired geriatrician manchester medical society, c/o john rylands university library, oxford road, manchester M13 9PP
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In addition to the risk of occlusion of the pulmonary vein(1) patients who undergo radiofrequency catheter ablation around the pulmonary region of the posterior left atrium run other risks. The posterior wall of the left atrium is adjacent to the oesophagus, and this makes it vulnerable to damage, including atrial-oesophageal fistula formation, during radiofrequency catheter ablation of atrial fibrillation(AF).Nine patients were reported who presented with this complication 10-16 days after radiofrequency catheter ablation of AF. Non-specific symptoms were fever and leukocytosis. Neurological deficits from air emboli occured in eight, and three had overt gastrointestinal bleeding. The diagnosis was established by computed tomography in three patients, and only by autopsy in six. All died(2) References (1) Lubitz SA., Fischer A., Fuster V Catheter ablation for atrial fubrillation British Medical Journal 2008:338:819-26 (2) Cummings JE., Schweikert RA., Saliba W et al Brief communication: atrial-esophageal fistula after radiofrequency ablation Annals of Internal Medicina 2006:144:572-4 Competing interests: None declared |
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Dr Su Sethi, consultant in public health medicine in specialised services North West Specialised Services Commissioning Team, Warrington, WA4 6HL
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It is well established that the Cox-Maze III operation is the gold standard for the surgical treatment of atrial fibrillation and regarded as curative (1). However its technical complexity has led to attempts to simplify the operation by recreating the atrial incisions (maze pattern) using different technologies such as radiofrequency energy, microwave, cryoablation, laser etc. The success rates of the newer technologies when combined with open heart cardiac surgery for other cardiac indications (valvular, CABG) has varied between 65%-95% at 6 months and 73 -87% at three years (2). Concomitant procedures are now regarded as good practice for symptomatic patients with atrial fibrillation who are regarded at high risk of death and major adverse cardiac events. Current interest is centred around bilateral closed chest thorascopic minimally invasive surgical approaches for atrial fibrillation. The advantages of this may be the ability to create the full Cox-Maze III lesion set via a minimally invasive approach. Another advantage may be shorter operative times as compared to percutaneous catheter ablation techniques. Centre experience has demonstrated efficacy, technical safety and feasibility although larger series and RCTs are needed comparing the stand alone surgical treatment of atrial fibrillation with different ablation energy technologies as well as against catheter ablation. (3) In addition technical improvements are expected that will ensure complete transmural lesions aimed at reducing recurrence. The above advances will necessitate offering of a team approach to the referral, investigation, management and follow-up of the patients with atrial fibrillation. Full characterisation of the arrhythmia, determination of lesion set required based on interpretation of electroanatomical mapping and decisions regarding clinical choice of intervention taking into account patient preference and risks. Follow-up surveillance will be important to monitor freedom from atrial fibrillation and to detect any tachyarrhythmias that may require repeat interventions either electrophysiological or surgical. References 1.Gillinov AM, Blackstone EH, McCarthy P. Atrial Fibrillation : current surgical options and their assessment. Ann Thorac Surg 2002; 74:2210-2217.2. 2.Calkins H, Brugada J, Packer DL, Cappato R, Chen S, Crijns HJ et al. Surgical ablation of atrial fibrillation : recommendations for personnel policy, procedures and follow-up. A report of the Heart Rhythm Society (HRS) Task Force on catheter and surgical ablation of atrial fibrillation, Heart Rhythm 2007;4:816-61. 3.Pruitt JC, Lazzara RR, Dworkin GH, et al. Totally Endoscopic Ablation of lone atrial fibrillation : Initial Clinical Experience. Ann Thorac Surg 2006; 81:1325-1331. Competing interests: None declared |
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