The Value Of Esophagography Before Catheter Ablation For Atrial Fibrillation In Ablation Strategy And Prevention Of Esophageal Injury

Objective:Catheter ablation(CA)is an effective method for the treatment of atrial fibrillation(AF).Since the esophagus is very close to the left atrium and pulmonary vein in anatomy,radiofrequency ablation or cryoablation can easily leads to esophageal injury and even fatal atrial esophageal fistula,it is necessary to take some effective measures to avoid esophageal injury during ablation.In this study,preoperative esophagography was used to evaluate the anatomical relationship between the esophagus and left atrial,and the esophageal dynamics,so as to optimize the safety strategy of atrial fibrillation catheter ablation and minimize esophageal injuryMethods:From January 2018 to October 2019,118 AF patients who underwent catheter ablation for the first time in our hospital were selected.Space position of the esophagus,left atrium and pulmonary veins was observed by preoperative cardiac enhanced CT angiography(CTA)and esophageal enhancement CT angiographyphy.The following data was measured and analyzed:?The distance between the ipsilateral pulmonary veins and the esophageal border;?Contact width between the posterior left atrium and the esophagus parallel to inferior pulmonary vein;?The shortest distance between the anterior wall of the esophagus and the posterior wall of the left atrium.According to the spatial relationship between the esophagus and the posterior wall of the left atrium and the pulmonary vein,the esophageal configuration was divided into two types:left(L)and non-left(NL).The optimal ablation strategy was developed based on the preoperative CT images.At the same time,78 patients were randomly selected to receive synchronous contrast angiography of esophagus and left pulmonary vein under DSA before ablation,so as to observe the position relationship between esophagus and left pulmonary vein and whether there is reflux and retention of contrast agent in the esophagus in real time,and further divide this group of patients into reflux group and non-reflux group.Combined with the real-time imaging results,the ablation safety strategy was further optimized(such as avoiding the overlapping area between the esophagus and the posterior wall of the left atrial,or reducing the ablation power and shortening the ablation time).After the operation,all the patients were treated with acid preparation and gastric dynamic drugs for 2 months or more,and the occurrence of symptoms related to esophageal injury was observed with follow-upResults:This study confirmed that L-type was most common in the two major esophageal configurations,which close to the left pulmonary veins,accounting for 86.4%of the 118 patients.The distance between the esophagus border and the left superior pulmonary vein(LSPV),left inferior pulmonary vein(LIPV),right superior pulmonary vein(RSPV)and right inferior pulmonary vein(RIPV)were 12.20±6.55mm?7.13±3.32mm?24.10±9.72mm?18.10±8.35mm,respectively,which was the closest to the left inferior pulmonary vein,and there were significant differences among the four group(p<0.05).The mean shortest distance(SD)between the esophagus and the posterior left atrium was 2.24±0.72mm,and 75.42%of patients had SD at the back of LIPV.The contact width between them at the inferior pulmonary vein planar was 18.12±4.54mm.The distance from esophagus to each pulmonary vein was also significantly different between L-type and NL-type:11.25±5.60mm vs 18.22±8.85mm(LSPV)?6.50±2.68mm vs 11.56±4.16mm(LIPV)?25.49±9.36mm vs 15.20±6.98mm(RSPV)?19.84±7.49mm vs 6.98±3.57mm(RIPV),all p<0.05.However,there was no significant difference in the distance from esophagus to each pulmonary vein between radiofrequency ablation and cryoablation patients(p>0.05).There was also no significant difference in general clinical data,distance from esophagus to posterior left atrium,contact width of them between the two esophageal route types and two operation groups(p>0.05).Among the 78 patients in the DSA esophagography group,the relationship between the esophagus and pulmonary vein was observed by LAO40 or 45° fluoroscopy,of which 60 patients(76.92%)had overlap between the esophagus and the left pulmonary vein.Contrast agent reflux and retention were observed in 19 patients(24.36%).During the follow-up,29 patients presented with clinical symptoms related to esophageal injury of different degrees,such as acid regurgitation,belching,retrosternal or upper abdominal pain,but no atrial esophageal fistula occurred.In DSA imaging group,the incidence of postoperative symptoms was 26.32%vs 18.64%for patients with and without feflux(P>0.05),and there was a statistical differences between the two groups in the history of digestive tract(7/19 vs 7/59,p=0.034).Conclusions:1?Real-time esophageal under DSA imaging method before catheter ablation is simple and convenient,it can judge the power status,presence of reflux of esophagus,also it can show the precise location of esophagus and pulmonary vein2?Preoperative esophageal CT angiography combined with cardiac CTA imaging 3d reconstruction can more fully display the 3d spatial structure of esophagus,left atrium and pulmonary vein,which is crucial for the selection of a reasonable ablation method and ablation target.3?In most patients,the esophagus is adjacent to the left pulmonary vein,especially more adjacent to LIPV.LIPV has a large contact area and the shortest distance with the esophagus Therefore,both radiofrequency ablation and cryoablation should be more cautious when ablation of LIPV.