Author + information
- Jian-Fang Ren, MD⁎ ( and )
- David J. Callans, MD
- ↵⁎Division of Cardiovascular Medicine, University of Pennsylvania Health System, 111 North 9th Street, Philadelphia, Pennsylvania 19107
In a recent issue of iJACC, Faletra et al. (1) reported real-time (RT) 3-dimensional (3D) transesophageal echocardiography (TEE) imaging of the left atrium (LA) and pulmonary veins (PVs) and described examples of its use during catheter-based PV ablation. RT 3D TEE may offer a useful tool to enhance our understanding and evaluation of cardiac structures during percutaneous treatment procedures. However, we disagree with Faletra et al. (1) to forecast that RT 3D TEE may become a useful complementary imaging modality in anatomy-driven radiofrequency (RF) PV isolation. We consider that patient safety is a serious concern with using RT 3D TEE during RF LA posterior wall (PW) and PV ablation.
The esophagus is immediately contiguous to the LAPW (Fig. 1). Esophageal injury has been reported with delivery of RF lesions at the LAPW contiguous to the esophagus during LA intraoperative or percutaneous transcatheter ablation for atrial fibrillation (2,3). Placement of the TEE probe in the esophagus pushes the anterior wall into the LAPW and increases both the contiguous area and the proximity, particularly in a dilated LA. This could certainly increase the risk of esophageal injury during LAPW ablation, such as atrioesophageal fistula/perforation. Because of the high mortality of this complication, avoiding and preventing esophageal injury is paramount during LA ablation procedures. In addition, the TEE transducer, when manipulated in the posteriorly limited esophageal space with its narrowing ultrasonic beam, is too close to visualize the entire LA roof and the posteriorly located and oriented right and left inferior veins. Finally, TEE requires an expert echocardiographer, is poorly tolerated by patients with prolonged placement, and requires heavy sedation and/or general anesthesia. These disadvantages have limited its routine use, especially during LA and PV ablation procedures.
In our laboratory, in addition to fluoroscopy, a 3D electroanatomic mapping system with real-time intracardiac echocardiographic imaging is the perfect combined technique for routine monitoring and guidance of LA and PV ablation for atrial fibrillation.
- American College of Cardiology Foundation