Proactive esophageal cooling protects against thermal insults during high-power short-duration radiofrequency cardiac ablation

[EN] Background Proactive cooling with a novel cooling device has been shown to reduce endoscopically identified thermal injury during radiofrequency (RF) ablation for the treatment of atrial fibrillation using medium power settings. We aimed to evaluate the effects of proactive cooling during high-power short-duration (HPSD) ablation. Methods A computer model accounting for the left atrium (1.5 mm thickness) and esophagus including the active cooling device was created. We used the Arrhenius equation to estimate the esophageal thermal damage during 50 W/ 10 s and 90 W/ 4 s RF ablations. Results With proactive esophageal cooling in place, temperatures in the esophageal tissue were significantly reduced from control conditions without cooling, and the resulting percentage of damage to the esophageal wall was reduced around 50%, restricting damage to the epi-esophageal region and consequently sparing the remainder of the esophageal tissue, including the mucosal surface. Lesions in the atrial wall remained transmural despite cooling, and maximum width barely changed (<0.8 mm). Conclusions Proactive esophageal cooling significantly reduces temperatures and the resulting fraction of damage in the esophagus during HPSD ablation. These findings offer a mechanistic rationale explaining the high degree of safety encountered to date using proactive esophageal cooling, and further underscore the fact that temperature monitoring is inadequate to avoid thermal damage to the esophagus.Research reported in this publication was supported by the National Heart, Lung, And Blood Institute of the National Institutes of Health under Award Number R44HL158375 (the content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health) and by the Spanish Ministerio de Ciencia, Innovacion y Universidades/Agencia Estatal de Investigacion (MCIN/AEI/10.13039/501100011033 under grant RTI2018-094357-B-C21).Mercado Montoya, M.; Gomez Bustamante, T.; Berjano, E.; Mickelsen, SR.; Daniels, JD.; Hernández Arango, P.; Schieber, J.... (2022). Proactive esophageal cooling protects against thermal insults during high-power short-duration radiofrequency cardiac ablation. International Journal of Hyperthermia. 39(1):1202-1212. https://doi.org/10.1080/02656736.2022.21218601202121239

Esophageal cooling for protection during left atrial ablation : a systematic review and meta-analysis

Thermal damage to the esophagus is a risk from radiofrequency (RF) ablation of the left atrium for the treatment of atrial fibrillation (AF). The most extreme type of thermal injury results in atrio-esophageal fistula (AEF) and a correspondingly high mortality rate. Various strategies for reducing esophageal injury have been developed, including power reduction, esophageal deviation, and esophageal cooling. One method of esophageal cooling involves the direct instillation of cold water or saline into the esophagus during RF ablation. Although this method provides limited heat-extraction capacity, studies of it have suggested potential benefit. We sought to perform a meta-analysis of published studies evaluating the use of esophageal cooling via direct liquid instillation for the reduction of thermal injury during RF ablation. We searched PubMed for studies that used esophageal cooling to protect the esophagus from thermal injury during RF ablation. We then performed a meta-analysis using a random effects model to calculate estimated effect size with 95% confidence intervals, with an outcome of esophageal lesions stratified by severity, as determined by post-procedure endoscopy. A total of 9 studies were identified and reviewed. After excluding preclinical and mathematical model studies, 3 were included in the meta-analysis, totaling 494 patients. Esophageal cooling showed a tendency to shift lesion severity downward, such that total lesions did not show a statistically significant change (OR 0.6, 95% CI 0.15 to 2.38). For high-grade lesions, a significant OR of 0.39 (95% CI 0.17 to 0.89) in favor of esophageal cooling was found, suggesting that esophageal cooling, even with a low-capacity thermal extraction technique, reduces the severity of lesions resulting from RF ablation. Esophageal cooling reduces the severity of the lesions that may result from RF ablation, even when relatively low heat extraction methods are used, such as the direct instillation of small volumes of cold liquid. Further investigation of this approach is warranted, particularly with higher heat extraction capacity techniques

Sex‐Specific Associations of Oral Anticoagulant Use and Cardiovascular Outcomes in Patients With Atrial Fibrillation

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/139084/1/jah32481-sup-0001-TableS1.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/139084/2/jah32481.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/139084/3/jah32481_am.pd

Esophageal cooling for protection during left atrial ablation: a systematic review and meta-analysis.

PURPOSE: Thermal damage to the esophagus is a risk from radiofrequency (RF) ablation of the left atrium for the treatment of atrial fibrillation (AF). The most extreme type of thermal injury results in atrio-esophageal fistula (AEF) and a correspondingly high mortality rate. Various strategies for reducing esophageal injury have been developed, including power reduction, esophageal deviation, and esophageal cooling. One method of esophageal cooling involves the direct instillation of cold water or saline into the esophagus during RF ablation. Although this method provides limited heat-extraction capacity, studies of it have suggested potential benefit. We sought to perform a meta-analysis of published studies evaluating the use of esophageal cooling via direct liquid instillation for the reduction of thermal injury during RF ablation. METHODS: We searched PubMed for studies that used esophageal cooling to protect the esophagus from thermal injury during RF ablation. We then performed a meta-analysis using a random effects model to calculate estimated effect size with 95% confidence intervals, with an outcome of esophageal lesions stratified by severity, as determined by post-procedure endoscopy. RESULTS: A total of 9 studies were identified and reviewed. After excluding preclinical and mathematical model studies, 3 were included in the meta-analysis, totaling 494 patients. Esophageal cooling showed a tendency to shift lesion severity downward, such that total lesions did not show a statistically significant change (OR 0.6, 95% CI 0.15 to 2.38). For high-grade lesions, a significant OR of 0.39 (95% CI 0.17 to 0.89) in favor of esophageal cooling was found, suggesting that esophageal cooling, even with a low-capacity thermal extraction technique, reduces the severity of lesions resulting from RF ablation. CONCLUSIONS: Esophageal cooling reduces the severity of the lesions that may result from RF ablation, even when relatively low heat extraction methods are used, such as the direct instillation of small volumes of cold liquid. Further investigation of this approach is warranted, particularly with higher heat extraction capacity techniques

Analysis of thermal effects from pulsed field ablation

Background Pulsed field ablation (PFA) has been described as non-thermal, but abundant data exist in oncology applications [1-3], and growing data are emerging in cardiology [4], highlighting that thermal effects are in fact present with PFA. The particular parameters (such as voltage, pulse gap, pulse number) that most influence the development of thermal energy during PFA are less clear. Purpose We sought to evaluate the thermal effects arising from pulsed field ablation of myocardial and esophageal tissue over a range of typical peak voltage operating conditions. Methods Using a three-dimensional computer model of the left atrium and esophagus, we quantified the thermal effects from PFA applications over a range of peak voltage operating conditions (1 kV, 1.5 kV, and 2 kV). Bipolar electroporation was simulated using one electrode as the anode and the other as a grounded cathode. Far-field and symmetry boundaries were set as electrically insulating. A monophasic waveform with a pulse duration of 100 µs and pause between pulses of 1 s was applied for a total of 50 pulses in a single train. Myocardial thickness was 1.5 mm, esophageal thickness was 2 mm, and the pericardial fat layer was varied between 0.3 and 0.75 mm. Results Minimal temperature rise in the esophagus was seen with 1 kV pulses (corresponding to 13.4 J input). With 1.5 kV and 2 kV peak voltages (corresponding to 32.3 J and 66.2 J), temperature elevations reaching 46.3 °C and > 62 °C were seen, respectively. These elevations occurred after only a single pulse train of 50 pulses, implying that further elevations in temperature would be seen with subsequent applications. Conclusions Thermal effects from PFA depend on total energy deposited, of which peak voltage is an important component. Current commercially available systems appear to have the potential to induce collateral thermal injury, particularly with a thin pericardial fat layer, and with repeated applications of pulsed field energy.Main funding source(s): National Heart, Lung, And Blood Institute of the National Institutes of Health under Award Number R44HL158375peer-reviewed2024-11-0

Impact of ultra-short pauses between stacked lesions with and without active esophageal cooling

Background Placing lesions at the same point (stacking lesions) in the left atrium during radiofrequency (RF) ablation can increase the risk of collateral injury. The use of active esophageal cooling has been shown to significantly reduce the risk of thermal injury to the esophagus, but stacking of lesions may overcome these protective effects. Longer pauses between lesions may reduce this risk, but the effect of very short pauses has not been previously quantified. Purpose To examine the impact of ultra-short pauses between stacked lesions with and without active esophageal cooling. Methods Using a computational model of the left atrium, we measured the effect of RF ablation in the left atrium on injury formation in the esophagus. Models with and without active esophageal cooling, using a dedicated esophageal cooling device, were created. Using a power of 50 W for 10 s, with up to 3 sequential lesions placed in the same location, we used the Arrhenius equation to quantify the fraction of damage (FOD) in the esophageal wall. The time between lesions was set to as short as 1 s, and results were compared to prior studies using longer pauses of up to 20 s. To account for thermal latency, measures of esophageal damage were taken both immediately after RF ablation, and again 90 s afterwards. Results With active cooling in place, esophageal injury was eliminated with active esophageal cooling after the first lesion placement, but reached 21% transmurality without cooling. Lesion transmurality increased after each lesion due to thermal latency, but active esophageal cooling prevented this effect when only one lesion was placed. Subsequent lesions resulted in esophageal injury when placed in the same location. After 3 lesions with 1 s pauses between each, esophageal injury transmurality reached 91% without cooling in place, and 22% with active cooling in place (Figure 1). In contrast, analysis of the intended lesions in the atrial wall demonstrated minimal effects from cooling (Figure 2). Conclusions Active esophageal cooling significantly reduces esophageal injury from RF ablation, but placing additional lesions at the same point can overcome the heat extraction capacity of a dedicated cooling device. Decreased time between lesions exacerbates this risk, with an ultra-short pause of one second posing the greatest risk.Research reported in this abstract was supported by the National Heart, Lung, And Blood Institute of the National Institutes of Health under Award Number R44HL158375 (the content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health).peer-reviewe

Neural networks supporting audiovisual integration for speech: A large-scale lesion study

Auditory and visual speech information are often strongly integrated resulting in perceptual enhancements for audiovisual (AV) speech over audio alone and sometimes yielding compelling illusory fusion percepts when AV cues are mismatched, the McGurk-MacDonald effect. Previous research has identified three candidate regions thought to be critical for AV speech integration: the posterior superior temporal sulcus (STS), early auditory cortex, and the posterior inferior frontal gyrus. We assess the causal involvement of these regions (and others) in the first large-scale (N&nbsp;=&nbsp;100) lesion-based study of AV speech integration. Two primary findings emerged. First, behavioral performance and lesion maps for AV enhancement and illusory fusion measures indicate that classic metrics of AV speech integration are not necessarily measuring the same process. Second, lesions involving superior temporal auditory, lateral occipital visual, and multisensory zones in the STS are the most disruptive to AV speech integration. Further, when AV speech integration fails, the nature of the failure-auditory vs visual capture-can be predicted from the location of the lesions. These findings show that AV speech processing is supported by unimodal auditory and visual cortices as well as multimodal regions such as the STS at their boundary. Motor related frontal regions do not appear to play a role in AV speech integration