{"id":15625,"date":"2023-04-18T06:30:09","date_gmt":"2023-04-18T06:30:09","guid":{"rendered":"https:\/\/endoscopiaterapeutica.net\/pt\/?p=15625"},"modified":"2023-04-18T11:35:52","modified_gmt":"2023-04-18T11:35:52","slug":"lesao-esofagica-pos-ablacao-cardiaca","status":"publish","type":"post","link":"https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/lesao-esofagica-pos-ablacao-cardiaca\/","title":{"rendered":"Les\u00e3o Esof\u00e1gica P\u00f3s-Abla\u00e7\u00e3o Card\u00edaca"},"content":{"rendered":"\n<p>A fibrila\u00e7\u00e3o atrial \u00e9 a arritmia card\u00edaca mais comum sendo o tratamento atrav\u00e9s da abla\u00e7\u00e3o indicado nos casos de doen\u00e7a refrat\u00e1ria \u00e0 medica\u00e7\u00e3o. Entretanto devido \u00e0 proximidade da parede posterior do \u00e1trio esquerdo com o es\u00f4fago (&lt; 5mm em 40% dos casos), associado a quantidade de energia desprendida no local (pot\u00eancia, tempo e for\u00e7a de contato), tornam o es\u00f4fago um potencial s\u00edtio de eventos adversos. <\/p>\n\n\n\n<p class=\"has-text-align-center has-very-light-gray-to-cyan-bluish-gray-gradient-background has-background has-medium-font-size\"><strong>Abaixo as poss\u00edveis complica\u00e7\u00f5es gastrointestinais p\u00f3s-abla\u00e7\u00e3o card\u00edaca<\/strong><\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>Dismotilidade do trato gastrointestinal superior<\/strong><\/h2>\n\n\n\n<p>O mecanismo exato dessas les\u00f5es n\u00e3o \u00e9 conhecido, por\u00e9m a les\u00e3o do nervo vago devido \u00e0 sua proximidade com o es\u00f4fago e a parede do \u00e1trio esquerdo, \u00e9 a teoria mais aceita. Curiosamente, a maior parte da dismotilidade parece ser subcl\u00ednica e muitas vezes diagnosticada incidentalmente.&nbsp;<\/p>\n\n\n\n<p>Os sintomas geralmente se iniciam 3 dias ap\u00f3s a abla\u00e7\u00e3o, sendo os mais comuns: refluxo, disfagia, dor tor\u00e1cica por hipomotilidade esof\u00e1gica, distens\u00e3o abdominal, saciedade precoce, perda de peso, n\u00e1useas e v\u00f4mitos.<\/p>\n\n\n\n<p>No \u00fanico estudo prospectivo observacional realizado, 74% dos pacientes submetidos a abla\u00e7\u00e3o desenvolveram alguma dismotilidade, por\u00e9m normalizada em at\u00e9 6 meses em todos os participantes<sup>1<\/sup>.<\/p>\n\n\n\n<p>O tratamento deve ser realizado nos casos sintom\u00e1ticos, com refei\u00e7\u00f5es em menores por\u00e7\u00f5es e baixo teor de gordura, al\u00e9m do uso de pr\u00f3-cin\u00e9ticos. Nos raros casos refrat\u00e1rios pode ser realizada toxina botul\u00ednica para espasmo pil\u00f3rico ou mesmo cirurgia.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>Les\u00f5es esof\u00e1gicas<\/strong><\/h2>\n\n\n\n<p>Estudos demonstram uma incid\u00eancia vari\u00e1vel de les\u00e3o esof\u00e1gica ap\u00f3s abla\u00e7\u00e3o por cateter, variando de 2% a 47%, sendo a grande maioria assintom\u00e1ticos. <\/p>\n\n\n\n<p>Durante a abla\u00e7\u00e3o, altas temperaturas s\u00e3o alcan\u00e7adas podendo causar danos ao es\u00f4fago, variando de eritema leve (mais comum e com \u00f3timo progn\u00f3stico) \u00e0 ulcera\u00e7\u00f5es e, em casos raros, pode levar a perfura\u00e7\u00e3o esof\u00e1gica e forma\u00e7\u00e3o de f\u00edstula atrioesof\u00e1gica<sup>2<\/sup>.&nbsp;<\/p>\n\n\n\n<p>Como as les\u00f5es esof\u00e1gicas assintom\u00e1ticas s\u00e3o comuns, a triagem endosc\u00f3pica precoce p\u00f3s abla\u00e7\u00e3o pode ajudar a identificar os pacientes com maior risco de perfura\u00e7\u00e3o esof\u00e1gica, permitindo vigil\u00e2ncia adequada. Abaixo a classifica\u00e7\u00e3o utilizada para esse estadiamento:<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><strong><em>Kansas City Classification (KCC)<sup>3<\/sup><\/em><\/strong><\/h3>\n\n\n\n<ul class=\"has-very-light-gray-to-cyan-bluish-gray-gradient-background has-background wp-block-list\">\n<li>Tipo 1: eritema<\/li>\n\n\n\n<li>Tipo 2A: \u00falcera mucosa superficial<\/li>\n\n\n\n<li>Tipo 2B: \u00falcera profunda&nbsp;<\/li>\n\n\n\n<li>Tipo 3A: perfura\u00e7\u00e3o esof\u00e1gica sem f\u00edstula atrioesof\u00e1gica<\/li>\n\n\n\n<li>Tipo 3B: perfura\u00e7\u00e3o esof\u00e1gica com f\u00edstula atrioesof\u00e1gica<\/li>\n<\/ul>\n\n\n\n<p>Em uma revis\u00e3o que incluiu 570 les\u00f5es esof\u00e1gicas avaliadas endoscopicamente em pacientes assintom\u00e1ticos, 36% eram tipo 1, 39% tipo 2A e 25% tipo 2B<sup>3<\/sup>. No entanto, a avalia\u00e7\u00e3o luminal do es\u00f4fago \u00e9 limitada \u00e0 superf\u00edcie e pode subestimar a extens\u00e3o do dano transmural, visto que as les\u00f5es s\u00e3o \u201cde fora para dentro\u201d.&nbsp;<sup>3; 4<\/sup><\/p>\n\n\n\n<p>Deve-se sempre lembrar que nos casos com suspeita de f\u00edstula (febre, dor tor\u00e1cica, odinofagia) a endoscopia \u00e9 contraindicada pelo risco de embolismo gasoso, devendo-se optar pela tomografia com contraste oral e endovenoso para avalia\u00e7\u00e3o.<\/p>\n\n\n<div class=\"wp-block-image\">\n<figure class=\"aligncenter size-full\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/figu-1.jpg\" data-rel=\"penci-gallery-image-content\" ><img fetchpriority=\"high\" decoding=\"async\" width=\"331\" height=\"247\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/figu-1.jpg\" alt=\"\" class=\"wp-image-15776\" srcset=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/figu-1.jpg?v=1681351205 331w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/figu-1-300x224.jpg?v=1681351205 300w\" sizes=\"(max-width: 331px) 100vw, 331px\" \/><\/a><figcaption class=\"wp-element-caption\"><strong>Figura 1: les\u00e3o KCC tipo 1<\/strong><br><\/figcaption><\/figure>\n<\/div>\n\n<div class=\"wp-block-image\">\n<figure class=\"aligncenter size-full\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/figu-2.jpg\" data-rel=\"penci-gallery-image-content\" ><img decoding=\"async\" width=\"343\" height=\"228\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/figu-2.jpg\" alt=\"\" class=\"wp-image-15778\" srcset=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/figu-2.jpg?v=1681351252 343w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/figu-2-300x199.jpg?v=1681351252 300w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/figu-2-263x175.jpg?v=1681351252 263w\" sizes=\"(max-width: 343px) 100vw, 343px\" \/><\/a><figcaption class=\"wp-element-caption\"><strong>Figura 2: les\u00e3o KCC tipo 2A<br><\/strong><\/figcaption><\/figure>\n<\/div>\n\n<div class=\"wp-block-image\">\n<figure class=\"aligncenter size-full\"><img decoding=\"async\" width=\"346\" height=\"254\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/figu-3.jpg\" alt=\"\" class=\"wp-image-15779\" srcset=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/figu-3.jpg?v=1681351297 346w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/figu-3-300x220.jpg?v=1681351297 300w\" sizes=\"(max-width: 346px) 100vw, 346px\" \/><figcaption class=\"wp-element-caption\"><strong>Figura 3: les\u00e3o KCC tipo 2B<br><\/strong><\/figcaption><\/figure>\n<\/div>\n\n\n<h2 class=\"wp-block-heading\"><strong>F\u00edstula atrioesof\u00e1gica<\/strong><\/h2>\n\n\n\n<p>A les\u00e3o t\u00e9rmica que leva \u00e0 isquemia e inflama\u00e7\u00e3o parece resultar em dano gradual e progressivo da parede esof\u00e1gica, o que pode explicar por que a perfura\u00e7\u00e3o esof\u00e1gica e posterior f\u00edstula podem levar de 2 a 4 semanas para se desenvolverem.<\/p>\n\n\n\n<p>\u00c9 uma rara, por\u00e9m grav\u00edssima complica\u00e7\u00e3o, com uma incid\u00eancia de 0,015 a 0,2%, apesar de provavelmente subnotificada. Sua complexidade decorre do diagn\u00f3stico tardio e falta de corre\u00e7\u00e3o cir\u00fargica a tempo<sup>2<\/sup>.&nbsp;<\/p>\n\n\n\n<p>Apresenta sinais cl\u00ednicos variados como febre, hemat\u00eamese, altera\u00e7\u00e3o do n\u00edvel de consci\u00eancia, dor tor\u00e1cica, disfagia, sepse, mediastinite, derrame pleural ou peric\u00e1rdico. Acidente vascular cerebral (embolia gasosa), septicemia e sangramento gastrointestinal (GI) s\u00e3o os principais fatores que contribuem para taxas de mortalidade que variam de 40% a 100%<sup>4<\/sup>.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>Conduta<\/strong><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li><em>Les\u00f5es tipo 1 e tipo 2A:<\/em> inibidor de bomba de pr\u00f3tons (IBP), resposta completa em 2 a 4 semanas<\/li>\n\n\n\n<li><em>Les\u00f5es 2B:<\/em> apresentam 4% de risco de progress\u00e3o para tipo 3. Interna\u00e7\u00e3o, jejum \/ l\u00edquidos claros e TC seriadas por 4 a 6 semanas.<\/li>\n\n\n\n<li><em>Les\u00f5es tipo 3:<\/em> uma revis\u00e3o de literatura demonstrou que o tratamento conservador ou stent esof\u00e1gico isolado parece ter um desfecho cl\u00ednico ruim, sendo o reparo cir\u00fargico precoce associado ou n\u00e3o a stent esof\u00e1gico a op\u00e7\u00e3o de escolha. Os resultados cl\u00ednicos da terapia combinada (cirurgia + stent) ainda s\u00e3o pouco claros devido ao n\u00famero reduzido de estudos<sup>5<\/sup>.<\/li>\n<\/ul>\n\n\n\n<p class=\"has-very-light-gray-to-cyan-bluish-gray-gradient-background has-background\"><strong>Nota: <\/strong>apesar de nenhum estudo randomizado ter comprovado o seu benef\u00edcio, a maioria dos servi\u00e7os indica periprocedimento e por um per\u00edodo de at\u00e9 6 semanas o uso rotineiro de IBP e sucralfato.<\/p>\n\n\n\n<p>Abaixo um fluxograma da conduta nos casos suspeitos:<\/p>\n\n\n<div class=\"wp-block-image\">\n<figure class=\"aligncenter size-large\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/fluxograma-lesao-de-esofago.png\" data-rel=\"penci-gallery-image-content\" ><img loading=\"lazy\" decoding=\"async\" width=\"576\" height=\"1024\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/fluxograma-lesao-de-esofago-576x1024.png\" alt=\"\" class=\"wp-image-15713\" srcset=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/fluxograma-lesao-de-esofago-576x1024.png 576w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/fluxograma-lesao-de-esofago-169x300.png 169w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/fluxograma-lesao-de-esofago-585x1040.png 585w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/fluxograma-lesao-de-esofago.png 720w\" sizes=\"(max-width: 576px) 100vw, 576px\" \/><\/a><\/figure>\n<\/div>\n\n\n<h2 class=\"wp-block-heading\"><strong>KEY POINTS<\/strong><\/h2>\n\n\n\n<ul class=\"has-pale-ocean-gradient-background has-background wp-block-list\">\n<li>IBP e sucralfato por 4 a 6 semanas<\/li>\n\n\n\n<li>EDA p\u00f3s abla\u00e7\u00e3o para estratifica\u00e7\u00e3o de risco<\/li>\n\n\n\n<li>TC na suspeita de perfura\u00e7\u00e3o<\/li>\n\n\n\n<li>Classifica\u00e7\u00e3o de Kansas&nbsp;<\/li>\n\n\n\n<li>Maioria assintom\u00e1ticos ou sintomas de dismotilidade autolimitados tratados com sintom\u00e1ticos<\/li>\n\n\n\n<li>Perfura\u00e7\u00e3o = tratamento cir\u00fargico precoce, associado ou n\u00e3o a stent esof\u00e1gico<\/li>\n<\/ul>\n\n\n\n<p><\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>Refer\u00eancias<\/strong><\/h2>\n\n\n\n<ol class=\"wp-block-list\">\n<li><sup> <\/sup>LAKKIREDDY, D.&nbsp; et al. Effect of atrial fibrillation ablation on gastric motility: the atrial fibrillation gut study. <strong>Circ Arrhythm Electrophysiol, <\/strong>v. 8, n. 3, p. 531-6, Jun 2015. ISSN 1941-3084. Dispon\u00edvel em: &lt; <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/25772541\">https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/25772541<\/a> &gt;.&nbsp;<\/li>\n\n\n\n<li>GARG, L.&nbsp; et al. Gastrointestinal complications associated with catheter ablation for atrial fibrillation. <strong>Int J Cardiol, <\/strong>v. 224, p. 424-430, Dec 01 2016. ISSN 1874-1754. Dispon\u00edvel em: &lt; <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/27690340\">https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/27690340<\/a> &gt;.&nbsp;<\/li>\n\n\n\n<li><sup> <\/sup>YARLAGADDA, B.&nbsp; et al. Temporal relationships between esophageal injury type and progression in patients undergoing atrial fibrillation catheter ablation. <strong>Heart Rhythm, <\/strong>v. 16, n. 2, p. 204-212, Feb 2019. ISSN 1556-3871. Dispon\u00edvel em: &lt; <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/30273767\">https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/30273767<\/a> &gt;.&nbsp;<\/li>\n\n\n\n<li>ASSIS, F. R.&nbsp; et al. Esophageal injury associated with catheter ablation for atrial fibrillation: Determinants of risk and protective strategies. <strong>J Cardiovasc Electrophysiol, <\/strong>v. 31, n. 6, p. 1364-1376, Jun 2020. ISSN 1540-8167. Dispon\u00edvel em: &lt; <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/32323383\">https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/32323383<\/a> &gt;.&nbsp;<\/li>\n\n\n\n<li><sup> <\/sup>ZHOU, B.&nbsp; et al. Treatment strategy for treating atrial-esophageal fistula: esophageal stenting or surgical repair?: A case report and literature review. <strong>Medicine (Baltimore), <\/strong>v. 95, n. 43, p. e5134, Oct 2016. ISSN 1536-5964. Dispon\u00edvel em: &lt; <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/27787367\">https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/27787367<\/a> &gt;.&nbsp;<\/li>\n<\/ol>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>Como citar este artigo<\/strong><\/h2>\n\n\n\n<p class=\"has-background\" style=\"background-color:#d7d8db82\">Oliveira JFD. Les\u00e3o Esof\u00e1gica P\u00f3s-Abla\u00e7\u00e3o Card\u00edaca. Endoscopia Terapeutica 2023 Vol 1. Dispon\u00edvel em: <a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/?p=15625\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/endoscopiaterapeutica.net\/pt\/lesao-esofagica-pos-ablacao-cardiaca\/<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"<p>A fibrila\u00e7\u00e3o atrial \u00e9 a arritmia card\u00edaca mais comum sendo o tratamento atrav\u00e9s da&hellip;<\/p>\n","protected":false},"author":2592,"featured_media":15630,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[151],"tags":[],"ano":[555],"tipo":[153],"volume":[263],"class_list":["post-15625","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-assuntosgerais","ano-555","tipo-endoscopia-digestiva-alta","volume-volume-i"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v27.2 (Yoast SEO v27.4) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>Les\u00e3o Esof\u00e1gica P\u00f3s-Abla\u00e7\u00e3o Card\u00edaca &#8226; Endoscopia Terapeutica<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/lesao-esofagica-pos-ablacao-cardiaca\/\" \/>\n<meta property=\"og:locale\" content=\"pt_BR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Les\u00e3o Esof\u00e1gica P\u00f3s-Abla\u00e7\u00e3o Card\u00edaca\" \/>\n<meta property=\"og:description\" content=\"A fibrila\u00e7\u00e3o atrial \u00e9 a arritmia card\u00edaca mais comum sendo o tratamento atrav\u00e9s da abla\u00e7\u00e3o indicado nos casos de doen\u00e7a refrat\u00e1ria \u00e0 medica\u00e7\u00e3o. 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