Further mechanistic evidence against luminal esophageal
temperature monitoring?
James Daniels, MD, Department of Internal Medicine, Cardiology, UT
Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390,
James.Daniels@utsouthwestern.edu
Erik Kulstad, MD, MS, Dept. of Emergency Medicine, UT Southwestern
Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390,
Erik.Kulstad@UTSouthwestern.edu
Corresponding author: Erik Kulstad, MD, MS, Dept. of Emergency Medicine,
UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX
75390,
Erik.Kulstad@UTSouthwestern.edu
Funding: None
Conflict of interest: EK declares equity interest in Attune Medical.
We congratulate Kar et al. on their elegant and insightful study
evaluating ex-vivo temperature profiles and the resulting thermal injury
formation on the epiesophageal surface during radiofrequency (RF)
ablation.[1] In addition to being the first study to detail
temperature profiles inclusive of the epiesophageal surface during RF
ablation, we believe that the results add further concern to the use of
temperature sensing technology in the quest to reduce esophageal injury.
Three recent clinical trials have evaluated the efficacy of luminal
esophageal temperature (LET) monitoring. The OPERA study, a randomized
controlled trial (RCT), demonstrated trends towards greater esophageal
lesion formation with the use of single-sensor LET monitoring when
ablating with standard power.[2] The AI-HP ESO II study demonstrated
trends towards greater esophageal lesion formation with multi-sensor LET
monitoring when ablating with ablation-index guided high-power.[3]
Most recently, an RCT by Grosse Meininghaus et al. found a 14% injury
rate using multi-sensor LET monitoring versus a 5% rate with no LET
monitoring (although the most severe lesion, a deep ulcer, was found in
the unmonitored group).[4]
Current recommendations only provide a Class IIa recommendation for LET
monitoring, with level of evidence C-EO (expert opinion), and have not
incorporated the latest data from these 3 studies demonstrating the lack
of benefit, and potential harm, from LET monitoring.[5] Kar et al.
found a lag time between the peak epiesophageal and endoluminal
temperatures of 13.0±11.0 seconds in standard ablation, and 24.2±22.1
seconds in high-power, short-duration (HPSD) ablation, with a gradient
between peak epiesophageal surface temperature and concurrent
endoluminal temperature of 1.7±2.0 °C in standard ablation and 5.1±5.3
°C in HPSD ablation. Thus, a mechanistic rationale for why LET
monitoring has not been shown to provide clinical benefit may be the
inability of any measurement technology to identify thermal insult
before it has occurred.
On the other hand, two pilot RCTs suggest benefits of active cooling,
and a large RCT, the IMPACT study, further confirms this benefit by
finding an 83% reduction in esophageal lesion formation using an active
cooling device.[6-8] With no degradation in ablation efficacy, as
well as a reduction/elimination of the need for fluoroscopy and reports
of shortened procedure time with active cooling technology, the data of
Kar et al., combined with growing clinical data, suggest that continued
use of LET monitoring may be unjustified.
1. Kar R, Post A, John M, Rook A, Razavi M: An initial ex vivo
evaluation of temperature profile and thermal injury formation on the
epiesophageal surface during radiofrequency ablation . J
Cardiovasc Electrophysiol 2021 doi: 10.1111/jce.14911 PMID: 33476464.
2. Schoene K, Arya A, Grashoff F, Knopp H, Weber A, Lerche M, König S,
Hilbert S, Kircher S, Bertagnolli L et al : Oesophageal
Probe Evaluation in Radiofrequency Ablation of Atrial Fibrillation
(OPERA): results from a prospective randomized trial . Europace2020 doi: 10.1093/europace/euaa209 PMID:
3. Chen S, Schmidt B, Seeger A, Bordignon S, Tohoku S, Willems F,
Urbanek L, Throm C, Konstantinou A, Plank K et al :Catheter ablation of atrial fibrillation using ablation
index-guided high power (50 W) for pulmonary vein isolation with or
without esophageal temperature probe (the AI-HP ESO II) . Heart
Rhythm 2020, 17 (11):1833-1840 doi: 10.1016/j.hrthm.2020.05.029
PMID: 32470628.
4. Meininghaus DG, Blembel K, Waniek C, Kruells-Muench J, Ernst H,
Kleemann T, Geller JC: Temperature Monitoring and
Temperature-driven irrigated Radiofrequency Energy Titration do not
prevent thermally-induced Esophageal Lesions in Pulmonary Vein Isolation
A randomized study controlled by esophagoscopy before and after catheter
ablation . Heart Rhythm 2021 doi: 10.1016/j.hrthm.2021.02.003
PMID: 33561587.
5. Calkins H, Hindricks G, Cappato R, Kim YH, Saad EB, Aguinaga L, Akar
JG, Badhwar V, Brugada J, Camm J et al : 2017
HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and
surgical ablation of atrial fibrillation: Executive summary .Europace 2018, 20 (1):157-208 doi:
10.1093/europace/eux275 PMID: 29016841.
6. Leung LWM, Bajpai A, Zuberi Z, Li A, Norman M, Kaba RA, Akhtar Z,
Evranos B, Gonna H, Harding I et al : Randomized
comparison of oesophageal protection with a temperature control device:
results of the IMPACT study . Europace 2020 doi:
10.1093/europace/euaa276 PMID: 33205201.
7. Clark B, Alvi N, Hanks J, Suprenant B: A Pilot Study of an
Esophageal Cooling Device During Radiofrequency Ablation for Atrial
Fibrillation . medRxiv 2020:2020.2001.2027.20019026 doi:
10.1101/2020.01.27.20019026 PMID:
8. Tschabrunn CM, Attalla S, Salas J, Frankel DS, Hyman MC, Simon E,
Sharkoski T, Callans DJ, Supple GE, Nazarian S et al :Active esophageal cooling for the prevention of thermal injury
during atrial fibrillation ablation: a randomized controlled pilot
study . J Interv Card Electrophysiol 2021 doi:
10.1007/s10840-021-00960-w PMID: 33620619.