World Journal of Cardiovascular Diseases, 2012, 2, 302-304 WJCD doi:10.4236/wjcd.2012.24047 Published Online October 2012 (http://www.SciRP.org/journal/wjcd/ ) Successful radiofrequency ablation of long-standing persistent atrial fibrillation in a patient with esophageal achalasia Andrea Avella 1* , Piergiuseppe De Girolamo 1 , Francesco Laurenzi 1 , Augusto Pappalardo 1 , Vitaliano Buffa 2 1 Cardiology Division and Cardiac Arrhythmia Unit, St. Camillo-Forlanini Hospital, Rome, Italy 2 Cardiovascular Imaging Unit, St. Camillo-Forlanini Hospital, Rome, Italy Email: * andrea.avella@tin.it Received 29 June 2012; revised 9 August 2012; accepted 20 August 2012 ABSTRACT A 54-year-old man was referred for ablation of symp- tomatic drug-refractory long-lasting persistent atrial fibrillation. His past medical history was negative for cardiac disease but included a diagnosis of esophageal achalasia. The patient underwent an ablation proce- dure, guided by barium esophagram, including isola- tion of the pulmonary veins, ablation of complex frac- tionated left atrial electrograms recorded on the septal wall and, finally, linear ablation of the cavo-tricuspid isthmus. The ablation procedure was performed with multielectrode ablation catheters using duty-cycled bi- polar/unipolar radiofrequency energy. During 6 months of follow-up no recurrences of atrial fibrillation were documented. The reported case demonstrates how an ablation procedure for long-standing persistent AF may be safely performed even in a patient presenting with a achalasia, outlining the mega-esophagus posi- tion with a simple barium paste. Keywords: Atrial Fibrillation; Ablation; Esophageal Achalasia 1. INTRODUCTION At the present time, a number of different approaches are being employed to avoid esophagus-related complica- tions during atrial fibrillation (AF) ablation procedures [1-6]. Barium paste, outlining the esophageal position in real time for the duration of the procedure, may provide an effective approach to minimize the potential risk of thermal injury when delivering radiofrequency (RF) en- ergy at the posterior wall of the left atrium (LA), in close proximity to the esophagus [7]. In the case we here report barium esophagram was successfully used to perform safely RF ablation of long- standing persistent AF in a patient with a megaesophagus due to achalasia, a rare neurodegenerative disease result- ing in abnormal esophageal motility and impaired relaxa- tion of lower esophageal sphincter [8]. 2. CASE PRESENTATION A 54-year-old man with symptomatic drug-refractory long- standing persistent AF was referred for catheter ablation after two failed electrical cardioversion. His past medical history was negative for structural heart disease but in- cluded a diagnosis of esophageal achalasia established 3 years earlier. On admission, cardiac and chest computed tomogra- phy (CT) documented four distinct pulmonary veins (PVs) connecting with a LA, being partially compressed by an evident mega-esophagus (Figure 1 panels A and B) with accumulation of undigested food and severe nar- rowing of its distal segment. After outlining the mega-esophagus position with a small barium paste, swallowed by the patient prior to conscious sedation, a 3-step ablation procedure was per- formed with multielectrode ablation catheters using duty- cycled bipolar/unipolar RF energy, (Medtronic - Abla- tion Frontiers, Carlsbad, CA, USA). Initially, electrical isolation of the four PVs was performed with a decapolar, circular, over-the-wire mapping and ablation catheter (Figure 1 panels C and D). Subsequently, an additional LA substrate modification was obtained targeting com- plex fractionated electrograms along LA septal wall (Figure 1 panel E) with a different multiarray ablation catheter. Finally, after restoration of the sinus rhythm by external electrical cardioversion, a linear ablation of the cavo-tricuspid isthmus was performed delivering RF energy with a specific hexapolar linear ablation catheter, until a bidirectional isthmus block was obtained (Figure 1 panel F). * Corresponding author. Published Online October 2012 in SciRes. http://www.scirp.org/journal/wjcd