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.