1247Similar rate of thermal esophageal lesions are found in patients alternatively assigned to high power short duration (70W, 8s) vs. lesion index guided (35W) ablation for atrial fibrillation
Authors: Brunelli M , Opara W , Schwaar M , John N , Isensee C , Lutze G , Adler J , Heitmann A , Michael T , Gottstein T , Schmidt H 
Published: June 2020

Abstract

Background
wide antral pulmonary vein (PV) catheter ablation (CA) in patients with atrial fibrillation (AF) is safe and effective when permanent trans-mural lesions are achieved without causing harm to surrounding anatomical structures. Atrio-esophageal fistula, due to its high mortality, is the most dreadful complication related to CA for AF, therefore alternative radiofrequency (RF) approaches to reduce or eliminate this complication are currently studied. The shallower but wider lesions of high power short duration (HPSD) ablation might represent a safe alternative.

Purpose
to compare the rate of thermal esophageal lesions in patients with paroxysmal and persistent AF undergoing CA assigned to the 2 different RF modality.

Methods
one-hundred patients with paroxysmal and 100 with persistent AF will be alternatively assigned to undergo CA with the FlexAbility™ (HPSD group: 70W, 41°, 8 seconds) or the TactiCath™ (LSI-group: 35W, 41°, LSI: 5-5.5 posterior wall, up to 6 anywhere else) catheter. A 3-D mapping system, a steerable sheath and adenosine-test (30mg) were used in all patients. Posterior wall (PW) isolation in addition to PV isolation was performed in all, and patients with persistent AF were additionally treated with mitral and cavotricuspid isthmus ablation. Insertion of an esophageal probe was always attempted, and all patients underwent upper endoscopy 24 to 48 hours after CA.

Results
between June and October 2019, 71 patients (68 ± 10 years old, 32 (45%) female, 44 (60%) paroxysmal AF, AF duration 58 ± 81 months) were alternatively assigned to HPSD (36, 51%) or LSI-guided (35, 49%) ablation. No differences in clinical characteristics were found between groups. After 45 ± 18min and 30 ± 14 min of procedural and RF time, all PVs were isolated, and all spontaneous and adenosine-induced reconnections treated. Successful PW isolation was achieved with an additional 8 ± 3 and 7 ± 3 min of procedural and RF time. When HPSD and LSI-guided groups are compared, a similar rate of clinically non-relevant and self-healing thermal lesions at endoscopy was found (10, 27.8% vs. 10, 28.6%). Independent of the treatment group, a higher peak temperature identified patients with esophageal lesions (43.2° vs. 42°; P=.0065). A peak temperature value of 43.1° best identify patients most likely to develop thermal lesions (AUC 0.71, SE 84%, SP 39%). Interestingly, none of the 11 patients in whom esophageal probe insertion was not possible or attempted developed thermal lesions in comparison to 20 (33%) patients who underwent esophageal temperature monitoring (P=.0046). Conclusions: no difference in thermal induced esophageal lesions were found when the two different RF approach (HPSD vs. LSI guided) were compared. Interestingly, lack of temperature monitoring with an esophageal probe is associated with no thermal lesions at endoscopy.