<div>Is Esophageal Temperature Management Needed During Cryoballoon Ablation
for Atrial Fibrillation?</div><div>Bachir Lakkis MD, Marwan M. Refaat, MD</div><div>Division of Cardiology, Department of Internal Medicine, American
University of Beirut Medical Center, Beirut, Lebanon</div><div>Running Title: Is Esophageal Temperature Management Needed During CBA
for AF?</div><div>Words: (excluding the title page and references): 462</div><div>Keywords: Catheter Ablation, Atrial Fibrillation, Heart Diseases,
Cardiovascular Diseases, Cardiac Arrhythmias</div><div>Funding: None</div><div>Disclosures: None</div><div>Corresponding Author:</div><div>Marwan M. Refaat, MD, FACC, FAHA, FHRS, FASE, FESC, FACP, FAAMA</div><div>Tenured Professor of Medicine</div><div>Director, Cardiovascular Fellowship Program</div><div>Department of Internal Medicine, Cardiovascular Medicine/Cardiac
Electrophysiology</div><div>Department of Biochemistry and Molecular Genetics</div><div>American University of Beirut Faculty of Medicine and Medical Center</div><div>PO Box 11-0236, Riad El-Solh 1107 2020- Beirut, Lebanon</div><div>US Address: 3 Dag Hammarskjold Plaza, 8th Floor, New York, NY 10017, USA</div><div>Office: +961-1-350000/+961-1-374374 Extension 5353 or Extension 5366
(Direct)</div><div>Atrial fibrillation (AF) is one of the most frequently occurring
arrhythmias globally. Risk factors such as aging, hypertension, cardiac
and pulmonary diseases, alcohol consumption, smoking, obesity and
obstructive sleep apnea play an important role in the development of
AF.(1-2) AF is a leading cause of ischemic stroke worldwide and is
associated with increased mortality. (3) AF management depends on four
pillars: risk factor management, anticoagulation depending on the
CHA₂DS₂-VASc
score, rate control and rhythm control. (4) The application of thermal
energy in ablation, such as in cryoablation, can cause rare
complications such as an esophageal injury, esophageal perforation and
atrial-esophageal fistula. (5,6). Numerous technologies have been
developed to avoid this problem and include esophageal temperature
surveillance, using reduced temperatures, real time visualization of the
esophagus in addition to making use of an esophageal cooling device.
(7-9)</div><div>In the current issue of the Journal of Cardiovascular Electrophysiology,
Sink et al. have conducted a single-center pilot study to assess the
utilization of an esophageal warming device to avoid the development of
esophageal thermal injury (ETI) while utilizing cryoballoon ablation
(CBA). Alternative studies have shown that using a cooling device has
been beneficial in reducing the risk of ETI formation for patients
undergoing RFA. (10,11) Thus, the authors have enrolled 42 patients
undergoing CBA with AF refractory to medical therapy and have randomized
them into 2 groups. In the first group, 23 patients undergoing CBA used
an esophageal warming device such as esophageal heat-exchange tube (WRM)
while the other 19 patients undergoing CBA used traditional luminal
esophageal temperature (LET) to monitor the esophageal temperatures. The
authors have conducted upper endoscopy monitoring of the esophagus the
next day and subsequently, classified ETI into 4 grades. They have
observed in the WRM group a paradoxical increase in ETI in comparison to
the other group which used LET. Moreover, the authors have perceived a
direct link between ETI formation, total freeze time and colder
temperature usage. However, this study has several limitations,
including the small population size. Furthermore, the study results are
based on a single device employment which is EnsoETM® device (Attune
Medical, Chicago, IL). Therefore, the effects of using other warming
devices are not known.</div><div>Overall, the authors should be praised on their efforts for conducting
the first pilot study to evaluate the effects of using an esophageal
warming device for patients undergoing CBA and for providing cardinal
insight into the safety of utilizing such a device. In addition, the
results of this study have tremendous clinical implications. Certainly,
patients undergoing CBA might benefit from using higher temperature
(above -51 °) and lower freezing time (&lt;300 seconds) to avert
developing ETI. Further studies incorporating more patients should be
conducted to elucidate whether using an esophageal warming device is
associated with a beneficial or a detrimental effect.</div><div>References</div><div>1. Kornej J, Börschel CS, Benjamin EJ, Schnabel RB. Epidemiology of
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