Discussion
Proactive esophageal cooling was recently cleared by the FDA to reduce
the likelihood of ablation-related esophageal injury resulting from RF
cardiac PVI ablation procedures, with a large multicenter review of over
25,000 patients showing significant reductions in atrioesophageal
fistula formation associated with proactive esophageal
cooling.8,11 In this first formal analysis of the
changes in EP lab throughput associated with the adoption of proactive
esophageal cooling, we found that the adoption of proactive esophageal
cooling was associated with a 43.5% increase in EP lab throughput when
compared to the throughput achieved with LET monitoring and esophageal
deviation. Moreover, this increase occurred despite the loss of one
operator each in two of the three sites analyzed. This increased lab
throughput is attributed to the reduced procedural duration achieved
with the use of proactive esophageal cooling.
Large reductions in procedure time have been found with the use of
proactive esophageal cooling. A study of 373 patients across two
hospital systems found that of the 198 procedures employing LET
monitoring the average procedure duration was 146 ± 51 minutes, while
the 175 cases that employed proactive esophageal cooling were
significantly shorter (p < 0.001) at 110 ± 39 minutes,
representing a 24.7% (36 minute) reduction in procedure
duration.9,10 A study of 2,280 patients that included
academic medical centers, community hospitals, and an integrated
healthcare delivery system found that patients treated with proactive
esophageal cooling had procedures that were on average 60 minutes
shorter (34.7% reduction) when compared to procedures employing LET
monitoring (p = 0.001).21 Of the 928 patients treated
with LET monitoring, the mean procedure duration was 173 ± 73 minutes,
while the 1,352 cases using proactive esophageal cooling had a mean
procedure duration of 113 ± 51 minutes.21 Reduced
procedure times result from the elimination of the need to react to
local overheating conditions that occur with LET monitoring, which
generally requires pausing the RF delivery and awaiting temperature
equilibration and/or repositioning the RF catheter to ablate in a
different region while the overheated site cools.10With proactive esophageal cooling, overheating is eliminated, allowing a
consistent point-to-point lesion progress without interruption.
Increased EP lab throughput via the adoption of proactive esophageal
cooling may facilitate reduction of patient
backlog.6,19 Improving throughput can lead to shorter
patient wait times between scheduling and receiving treatment, an
important aspect of reducing morbidity and risk of developing more
persistent atrial fibrillation associated with delay in receiving
care.22 By reducing wait time, patient outcomes may
therefore improve. In addition to reducing patient wait times, shorter
procedure times have been associated with improved overall outcome, as
longer procedures are often associated with a higher likelihood for
complications.18