Other Considerations
The risk of atrioesophageal fistula remains a major concern with endocardial ablation involving the left atrial posterior wall. Endocardial ablation of non-paroxysmal atrial fibrillation often involves significant energy application in the vicinity of the esophagus, particularly when complete isolation of the posterior wall is a goal. Esophageal temperature monitoring is routinely used, but guidelines for acceptable temperature deviation are lacking. Further, evidence that temperature monitoring prevents esophageal injury is limited, as evidenced by the continued incidence of this terrible complication. The Hybrid Convergent procedure benefits from a unique catheter design which directs energy away from the esophagus and toward the epicardial left atrial posterior wall. In addition, the pericardial space is irrigated with saline during energy application. Far less endocardial ablation is required near the posterior wall to complete the lesion set. These factors result in less esophageal heating, and presumable a lower risk of esophageal injury. The ability of the Convergent procedure to provide durable transmural left atrial posterior wall isolation while minimizing risk of esophageal injury may be an important consideration in patient selection.