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