147 Mechanical Esophageal Displacement During Catheter Ablation for Atrial Fibrillation JACOB S. KORUTH, M.D., VIVEK Y. REDDY, M.D., MARC A. MILLER, M.D., KALPESH K. PATEL, M.D., JAMES O. COFFEY, M.D., AVI FISCHER, M.D., J. ANTHONY GOMES, M.D., SRINIVAS DUKKIPATI, M.D., ANDRE D’AVILA, M.D., and ALEXANDER MITTNACHT, M.D. From the Mount Sinai School of Medicine, New York City, New York, USA Esophageal Deviation in AF Ablation. Objective: To determine the feasibility and safety of esophageal displacement during atrial fibrillation (AF) ablation, to prevent thermal injury. Background: Patients undergoing AF ablation are at risk of esophageal thermal injury, which ranges from superficial ulceration, to gastroparesis, to the rare but catastrophic atrioesophageal fistula. A common approach to avoid damage is luminal esophageal temperature (LET) monitoring; however, (1) temperature rises mandate interruptions in energy delivery that interrupt workflow and potentially decrease procedural efficacy, and (2) esophageal fistulas have been reported even with LET monitoring. Methods: A cohort of 20 consecutive patients undergoing radiofrequency (RF) (16 patients) or laser balloon (4 patients) ablation of AF under general anesthesia. After barium instillation, the esophagus was deviated using an endotracheal stylet placed within a thoracic chest tube. LET monitoring was used during catheter ablation. Upper GI endoscopy was performed prior to discharge. Results: At the pulmonary vein level, leftward deviation measured 2.8 ± 1.6 cm (range: 0.4–5.7) and rightward deviation 2.8 ± 1.8 cm (range: 0.5–4.9). The temperature rose to >38.5 ◦ C in 3/20 (15%) patients. In these 3 patients, there was an average of 2 applications/patient that recorded temperatures >38.5 ◦ C. No patient had a temperature rise > 40 ◦ C. Endoscopy revealed no esophageal ulceration from thermal injury in 18/19 (95%) patients; the sole patient with a thermally mediated ulceration had an unusual esophageal diverticulum fully across the posterior left atrium. Twelve patients (63%) exhibited trauma related to instrumentation with no clinical sequelae. Conclusions: Mechanical esophageal deviation is feasible and allows for uninterrupted energy delivery along the posterior wall during catheter ablation of AF. (J Cardiovasc Electrophysiol, Vol. 23, pp. 147-154, February 2012) atrial fibrillation, catheter ablation, esophagus, esophageal temperature monitoring, pulmonary vein isolation Introduction Catheter ablation of atrial fibrillation (AF) is increasingly employed in the management of symptomatic AF. 1,2 The overall complication rates for AF ablation have declined, but the development of atrioesophageal fistula remains one of its most feared complications due to the potentially catastrophic outcome. 2 Several strategies have been described to help pre- vent or reduce gastroesophageal injury during AF ablation. These include luminal esophageal temperature (LET) mon- itoring, 3 determination of the anatomical relationship of the esophagus to the posterior LA with preprocedural or real- time imaging, 4-6 and modulation of power and duration of No disclosures. Address for correspondence: Vivek Y. Reddy, M.D., Helmsley Elec- trophysiology Center, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA. Fax: +646-537-9691; E-mail: vivek.reddy@mountsinai.org Manuscript received 8 April 2011; Revised manuscript received 17 June 2011; Accepted for publication 8 July 2011. doi: 10.1111/j.1540-8167.2011.02162.x radiofrequency lesions. 7 These approaches, even when ap- plied in combination, have failed to prevent atrioesophageal fistula formation. 8,9 Moreover, these strategies do not ad- dress the need to reduce of other forms of injury such as gastroesophageal motility disorders that originate from in- jury to vagal nerves that surround the esophagus. In addition, LET monitoring focuses on the early detection of thermal injury and often results in modification of the lesion sets, i.e., by directing the encircling lesions to be either more ostial or further midline in order to avoid temperature rises. Such mod- ifications increase the risk of pulmonary vein (PV) stenosis and “gaps” that may affect the long-term clinical success of the ablation procedure. Frequent premature lesion termina- tions and power reductions may also compromise chronic PV isolation rates, an endpoint critical to the long-term outcomes of AF ablation. On the other hand, there have been 2 reports on the use of either an endoscope 10 or transesophageal echocardiographic (TEE) probe 11 to mechanically displace the esophagus lat- erally away from the point of endocardial ablation along the posterior left atrium (LA). This approach is unique in that it has the potential to reduce gastroesophageal injury by actively displacing the primary organ at risk, i.e., the esopha- gus. Because of the logistical difficulties attendant with these