EP Lab Digest - January 2008 - (Page 22) 22 EP TECHNOLOGY JANUARY 2008 Detection of Esophageal Injury After AF Ablation Interview by Jodie Elrod I n a recent abstract presented at this year’s American College of Gastroenterology meeting, researchers evaluated the utility of esophageal capsule endoscopy for early identification of post radiofrequency ablation (RFA) related esophageal injury. Their abstract, entitled “Use of PillCam ESO ® Endoscopy for Early Detection of Esophageal Injury after Radiofrequency Ablation Therapy for Atrial Fibrilation,” determined that capsule endoscopy can be a helpful tool in the early diagnosis of esophageal injury after radiofrequency ablation. In this article we speak with lead author Milan Dodig, MD, from the Department of Gastroenterology and Hepatology at the Cleveland Clinic Foundation. and Saliba raised awareness of this complication; they both were instrumental in the initiation of esophageal imaging in their patients, in an effort to improve care and identify patients at possible risk for development of serious complications after the ablation procedure. 1 Figure 1. The PillCam ESO. Is PillCam ESO and the Given Imaging System also currently used for gastroenterology procedures? Yes, PillCam ESO was developed for patients suffering from esophageal disorders, such as esophageal varices, which may result in fatal bleeding, and Barrett’s esophagus, which is an early indication for esophageal cancer. It provides a patient-friendly alternative to esophageal endoscopy and the associated sedation and discomfort. PillCam ESO contains an imaging device and light source at both ends of the capsule and takes up to 14 images per second — a total of 2,600 color images — as it passes down the esophagus. How long has esophageal capsule endoscopy been available? PillCam ESO received FDA approval in November 2004 and received a permanent CPT® Code by the American Medical Association and the Center for Medicare and Medicaid Services effective January 1, 2007. This was just a small pilot study designed to see if this imaging approach was adequate in this particular indication. We are encouraged with the results and will proceed with a larger trial soon. disposable PillCam ESO through the GI tract. It is passed naturally and painlessly from the body, usually within 24 to 72 hours. endoscopy. However, in my opinion, capsule endoscopy is more suited for this due to its simplicity. In addition, with capsule endoscopy, results are readily available, there is no need for an endoscopy room and staff, and the patient does not need additional sedation during the procedure. EGD with insuflation of the esophagus could be potentially hazardous if transmural injuries of the esophageal wall predispose the patient to esophageal perforation. What made you decide to use this for identification of RFArelated esophageal injuries? Our rationale for using esophageal imaging after ablation therapy for atrial fibrillation (AF) was the potential for esophageal injury with energy used during the ablation procedure.The proximity of the esophageal wall to the area that is ablated in the heart may result in transmural injury of esophagus, leading to discomfort, and, more seriously, development of atrial-esophageal fistula (although this is encountered very rarely). Recently an article by Drs. Natale How is this technology used? Describe how the PillCam ESO and the Given Imaging System are used during a procedure to look for atrial fibrillation ablation related esophageal injury. The patient fasts for two hours, then swallows the PillCam ESO video capsule with a glass of water while lying on his or her back. After swallowing PillCam ESO, the patient is raised by 30-degree angles every two minutes over a six-minute ingestion period, until he or she is sitting upright. The total procedure takes approximately 20 minutes and can be performed in the doctor's office, hospital, or clinic. Natural digestive contractions help propel the How soon can esophageal capsule endoscopy be used after atrial fibrillation ablation to look for ablation-related injury? The patient needs to be fully awake to participate in the test.The test can be performed and interpreted the same day, after the ablation is performed. In our proposed trial design, most patients will have capsule endoscopy within 24 hours of ablation. How many AF patients were tested using this technology? Were there any adverse reactions? Our preliminary results suggest that esophageal injury happen in patients (we identified positive ESO findings in 7 out of 32 total patients). None of our patients developed AE fistula or any long-term complications in the esophagus.We used our findings to identify and follow these patients more closely for What methods, if any, are currently used to diagnose RFArelated esophageal injury? There is no consensus or guidelines currently.Two methods that can be used at this time are esophagogastroduodenoscopy (EGD) and capsule
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