4 Discussion
This is the first analysis of the role active esophageal cooling may
play in reducing the incidence of post-ablative chest pain following RF
ablation. After adoption, a significant reduction in post-ablation chest
pain was found, despite an increased use of posterior wall ablation
beyond standard PVI. These findings are in agreement with an operator
survey presented recently, in which electrophysiologists reported a 58%
reduction in patient complaints of post-ablative chest pain after
adopting active esophageal cooling.19 Another recent
analysis of 175 patients found that chest pain was reported by 18% of
patients treated with LET monitoring, but only 6% of patients treated
with active esophageal cooling (P=<0.001).20
Limited data exist showing any method to be successful in preventing
post-procedural chest pain, despite its high frequency of
occurrence.5,7 Nakhla et al.5examined the incidence of post-ablation acute pericarditis among 2,215
patients. Overall, 10.2% of the patients experienced suspected
post-ablation acute pericarditis, defined as chest pain requiring
treatment with anti-inflammatory drugs.5
Multiple studies have sought to establish prophylactic treatment
protocols for acute procedure-related pericarditis, but effective
treatment regimens remain elusive.11 In a prospective
study of 1,075 patients undergoing RF ablations, prophylactic use of
colchicine given at 0.3 mg twice daily ranging from 7 days to 1 month
prior to ablation was found to reduce the incidence of post-ablation
chest pain.8 However, the study was neither randomized
nor blinded, which may limit the generalizability of its findings. In
contrast, a randomized study of 139 patients did not demonstrate a clear
relationship between post-ablation acute pericarditis and prophylactic
colchicine use.9 This study observed no difference in
incidence of chest pain in patients given 0.6 mg of colchicine twice
daily and patients receiving standard post-ablation care without
colchicine. However, there was a significant increase in
gastrointestinal side effects in the group that received colchicine.
Additionally, a retrospective observational study of 205 patients found
that when colchicine was given at 0.6 mg twice daily for two weeks prior
to a procedure it was not associated with a significant reduction in
post-ablation chest pain, acute pericarditis, hospitalization, or AF
recurrence rates.21 However, colchicine was associated
with increased gastrointestinal side effects.21Despite significant energy and resources dedicated to elucidating a
definitive prophylactic treatment for post-ablation chest pain, little
progress has been made. The use of active esophageal cooling may offer a
simple and readily available option to address this problem.
In addition to improving patient quality of life, the reduction in the
incidence of post-ablation chest pain through the use of esophageal
cooling may in turn reduce the cost of medical care for patients. In a
review of the National Inpatient Sample from 2009 to 2014, the incidence
of post-ablation acute pericarditis hospitalizations was reported to
have almost tripled, rising from a frequency of 46 hospitalizations in
2009 to 130 hospitalizations in 2014.6 These
hospitalizations resulted in higher mean cost spent on care compared to
patients who did not experience post-ablation acute
pericarditis.6
As with any retrospective review, unmeasured confounders may exist that
bias the results; however, the focus on a single operator using the same
ablation technique and tools over the timeframe analyzed may serve to
minimize this source of bias. Moreover, factors that are associated with
increased post-ablation chest pain, such as the use of additional
posterior wall ablation, were found to have increased after the adoption
of cooling. Our data came from a single-site community hospital, and as
such, variation in staff experience, procedural approaches, and other
factors may affect the generalizability of the results. Nevertheless,
these findings are in agreement with survey data and recently presented
data from other hospital systems, which may serve to support the
reliability of the conclusions.