CORRESPONDENCE: LETTER TO THE EDITOR
Real-Time Intracardiac Echocardiographic Imaging of the Posterior Left Atrial Wall Contiguous to Anterior Wall of the Esophagus
Jian-Fang Ren, MD, FACC*,
Francis E. Marchlinski, MD, FACC and
David J. Callans, MD, FACC
* Division of Cardiovascular Medicine, Department of Medicine, University of Pennsylvania, School of Medicine, MSRL Building at Presbyterian Medical Center, 39th and Market Streets, Philadelphia, Pennsylvania 19104-2692 (Email: jian-fang.ren{at}uphs.upenn.edu).
In a recent issue of the Journal, Good et al. (1) reported that esophageal location and movement during left atrial ablation can be detected using a barium ingestion–digital cine-fluoroscopic imaging technique. The disadvantages of the barium ingestion–cine-fluoroscopic imaging technique, which they used in the report, include; 1) no real-time imaging during energy delivery of the left atrial posterior wall contiguous to the anterior esophageal wall, which is the most important/only region to be imaged and protected; 2) gaps in barium contrast of the entire esophageal mucosa border that may provide misleading information of the extent of contact along the contiguous posterior left atrial wall; 3) an active effect of barium ingestion on esophageal luminal diameter and movement; and 4) risk of aspiration. In addition, Figures 1A and 1B in the report (1) compare differing anteroposterior projections, creating the illusion of movement that should have been confirmed with the same angled projection.
Intracardiac echocardiography (ICE) can provide real-time imaging of the left atrial posterior wall contiguous to the anterior esophageal wall during energy delivery for left atrial ablation (2). Our ICE studies of esophageal imaging in more than 235 patients showed that the left atrial posterior wall contiguous to the anterior esophageal wall can be imaged in each case. This imaging technique can provide real-time anatomic imaging of this region (3). In addition to anatomic imaging of this region, the ablation catheter tip location and creation of echogenic lesions can also be evaluated during real-time ICE imaging (4). The ICE imaging can guide changes in the energy-delivery strategy to protect the esophagus from damage during ablation in this region and allow for safe lesion delivery in closer proximity to the esophagus than can be safely recommended with the barium ingestion–cine-fluoroscopic imaging technique.
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Footnotes
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Please note: Drs. Ren and Callans are the faculty members of AcuNav peer training courses and have received honorarium for the training courses.
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References
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1. Good E, Oral H, Lemola K, et al. Movement of the esophagus during left atrial catheter ablation for atrial fibrillation J Am Coll Cardiol 2005;46:2107-2110.[Abstract/Free Full Text]2. Ren JF, Marchlinski FE, Callans DJ. Esophageal imaging characteristics structural measurement during left atrial ablation for atrial fibrillationan intracardiac echocardiographic study. (abstr) J Am Coll Cardiol 2005;45(Suppl A):114A. 3. Ren JF, Marchlinski FE, Callans DJ, Schwartzman D. Practical Intracardiac Echocardiography in Electrophysiology. Oxford, UK: Blackwell Futura; 2005194–203. 4. Ren JF, Callans DJ, Marchlinski FE, Nayak H, Lin D, Gerstenfeld EP. Avoiding esophageal injury with power titration during left atrial ablation for atrial fibrillationan intracardiac echocardiographic imaging study. (abstr) J Am Coll Cardiol 2005;45(Suppl A):114A.
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