Clinical characteristics and management of periesophageal vagal nerve injury complicating left atrial ablation of atrial fibrillation: lessons from eleven cases

Abstract

Introduction: This study aimed to elucidate the clinical characteristics and management of periesophageal vagal nerve injury complicating the ablation of atrial fibrillation (AF).

Methods and results: A total of 3,695 patients with drug-resistant AF underwent extensive pulmonary vein isolation at our institution. Either a nonirrigated or an irrigated ablation catheter was employed, with radiofrequency power of 25-40 W. Esophageal temperature was monitored in 3,538 patients: when the esophageal temperature reached 42°C radiofrequency delivery was stopped. A total of 11 patients (60 ± 11 years, 10 males) were diagnosed as having a periesophageal vagal nerve injury after the AF ablation. Symptoms included nausea, vomiting, bloating, constipation, and gastric pain, which occurred within 72 hours after the procedure. Gastrointestinal fluoroscopy and/or endoscopy revealed gastric hypomotility (10 patients) and pyloric spasm (1 patient). Intravenous erythromycin (3 mg/kg every 8 hours) was effective in relieving symptoms in 5 patients, and the patient with pyloric spasm underwent esophagojejunal anstomosis. Eight patients almost fully recovered within 40 days; however, 3 patients suffered from severe symptoms for 3-12 months. This complication occurred in 4 of the 157 patients (2.5%) who did not have esophageal temperature monitoring, and 7 of the 3,538 (0.2%) who did (P = 0.0007). The 3 patients with persistent severe symptoms received no esophageal temperature monitoring.

Conclusion: The clinical course and severity of the periesophageal vagal nerve injury varied, but most patients finally recovered with conservative treatment. Radiofrequency delivery under esophageal temperature monitoring might reduce both the incidence and the severity of this complication.

Keywords: atrial fibrillation; catheter ablation; complication; esophageal temperature monitoring; gastric motility dysfunction; periesophageal vagal nerve injury.