RESUMO
Esophageal thermal injury is one of the most feared risks of ablation of the posterior left atrium despite the various devices used to monitor esophageal temperature or deviate the esophagus. Reactive cooling, in which cold water is manually instilled into the esophagus via an orogastric tube in response to rises in luminal esophageal temperature (LET), has been used by operators, but the availability of a dedicated esophageal cooling device offers the ability to provide proactive esophageal cooling without having to react to individual temperature rises in the esophagus. The objective of this study was to evaluate the feasibility of using a commercially available esophageal cooling device to provide esophageal protection during left atrial catheter ablation, then to compare this approach to standard LET monitoring with reactive cooling via manual cold-water instillation. In this study, we randomized 6 patients undergoing catheter ablation for atrial fibrillation. Three patients received the standard of care for our site (use of a single-sensor temperature probe, with adjunct ice-water instillation for any temperature increases of >1°C). Three patients underwent standard ablation after placement of the esophageal cooling device at a circulating water temperature of 4°C, without the use of any esophageal temperature monitoring. All patients underwent transesophageal echocardiography and esophagogastroduodenoscopy on the day prior to the ablation, followed by a second esophagogastroduodenoscopy the day after. The 6 patients in this study were enrolled between March and August 2018. In the 3 control patients, 1 had no evidence of esophageal mucosal damage, 1 had diffuse sloughing of the esophageal mucosa and multiple ulcerations, and 1 had a superficial ulcer with a large clot. Both patients with lesions were classified as 2a cases using the Zargar grading scheme for caustic injury. In the 3 patients treated with the cooling device, 1 had no evidence of esophageal mucosal damage, 1 had esophageal erythema (Zargar grade 1), and 1 had a solitary Zargar grade 2a lesion. At 3 months of follow-up, 1 patient in each group had recurrence of atrial fibrillation. Although a number of subsequent studies have confirmed the reduction of esophageal injury with the use of proactive esophageal cooling, this study is the only one to date to compare reactive cooling (via manual cold-water instillation) and proactive cooling (via a dedicated esophageal cooling device). Moreover, this is the first study to support the feasibility of using a dedicated cooling device for this purpose and provides the basis for further investigation.
RESUMO
PURPOSE: We sought to quantify the capabilities of a commercially available cooling device to protect the esophagus from RF injury in an animal model and develop a mathematical model to describe the system and provide a framework from which to advance this technology. METHODS: A series of ablations (10 W, duration 30-45 seconds) were performed directly on exposed swine esophagus. Control ablations were performed with static 37°C water, and treatment ablations were performed with water (range 5°C-37°C) circulating within the device. Mucosal lesions were evaluated visually and with target tissue histology. A mathematical model was then developed and compared against the experimental data. RESULTS: All 23 ablations (100%) performed under control conditions produced visible external esophageal lesions; 12 of these (52%) were transmural. Under treatment conditions, only 5 of 23 ablations (22%) produced visible external lesions; none (0%) were transmural. Transmurality of lesions decreased as circulating water temperature decreased, with absolute reduction ranging from 5.1% with the use of 37°C water (p=0.7) to 44.5% with the use of 5°C water (p<0.001). Comparison to the mathematical model showed an R^2 of 0.75, representing good agreement. CONCLUSION: Under worst-case conditions, with RF energy applied directly to the adventitial side of the esophagus, internal esophageal cooling with an esophageal cooling device provides significant protective effect from thermal injury. A mathematical model of the process provides a means to further investigate this approach to preventing esophageal injury during RF ablation and can serve to guide ongoing clinical investigations currently in progress.
RESUMO
Soils of all types and locations have generally served as the major sources of streptomycetous bacteria. These organisms are the source of nearly 80% of the world's antibiotics. Now, it is realized that Streptomyces spp. (within the group of prokaryotic filamentous bacteria known as actinomycetes) can exist as endophytes within the interstices of some higher plants. While it is sometimes possible to isolate one or two different streptomycetes from certain plants, most plants are free of these organisms. However, the snakevine (Kennedia nigricans) of the Northern Territory of Australia has yielded at least 39 different endophytic actinomycetes (95% of them being Streptomyces spp.) Most of these isolates possessed no detectable antibiotic properties, while at least seven had antibacterial and antifungal activities. Examination of eight selected cultures by scanning electron microscopy (SEM) as well as environmental scanning electron microcopy (FEI ESEM FEG) (FEI Company, Hillsobro, Ore., USA) revealed unusual patterns, structures, and features of the spores and hyphae of these microorganisms. For instance, as revealed by ESEM FEG for the first time, it has become obvious that extremely fine hair-like structures (average 25-49 nm with gold-coated specimens) exist on the spores and hyphae of some endophytic streptomycetes. The biological purpose of these hair-like protrusions is unknown. Both SEM and ESEM FEG can be effectively used as tools in identification and elucidation of the biology of these organisms. In addition, unusual colony morphology, observed with the unaided eye can very easily be used to distinguish some of these isolates since characteristic donut and pseudo-horn shaped colonies appeared in culture.
