Case presentation
Since the first report in 2001, esophageal radiofrequency (RF) therapy has proven to be safe and effective in treating refractory gastroesophageal reflux disease (GERD) [1,2]. More than 25,000 refractory GERD patents have undergone RF therapy over the last 17 years [2,3]. However, is it a safe choice for patients with refractory GERD and other comorbidities? Here, we report a case of acute myocardial infarction (AMI) followed by RF therapy. Although acute coronary disease can exist simultaneously with GERD [3,4], to the best of our knowledge, no reports describe ACI followed by RF therapy in GERD patients.
A 62-year-old man presented with a 4-year history of heartburn. The symptoms were aggravated by lying down and relieved by proton pump inhibitors (PPIs). He has a history of high blood pressure. Calcium channel blockers were taken routinely, and blood pressure was controlled well. Laboratory investigation was normal except for high cholesterol (5.6 mmol/L). Esophagogastroduodenoscopy (EGD) was normal. Esophageal motility was normal, but lower esophageal sphincter (LES) pressure was 5.8 mmHg. The 24-hour pH showed an acid exposure time (AET) of 9.1%, a DeMeester score of 31.29, and 109 reflux episodes.
Esophageal RF therapy was implemented to reduce or even stop PPIs usage. Under general anesthesia with endotracheal intubation, RF therapy was performed successfully in 40 minutes. Immediately after the delivery of RF energy, heat-induced small cautery burns were seen around the cardia (arrow) (Figure A, B). Eight hours after the procedure, the patient suddenly complained of more severe heartburn accompanied by chest pain and pressing feelings. The emergency white blood cell (WBC) count was 13.5x109/L, cardiac troponin was positive, and electrocardiogram (ECG) showed obviously elevated V1-V3. AMI was confirmed with subsequent coronary angiography which showed 80% stent of the left anterior descending coronary artery (arrow) (Figure C). And his symptom was disappeared followed by the stent implantation into the stenosis vessel (arrow) (Figure D).
This case underscores the importance of excluding coronary artery disease (CAD) in patients with GERD, especially those with risk factors for CAD, before RF therapy. Since the distal esophagus and heart are adjacent and share a common afferent vagal supply, the delivery of RF in the distal esophagus and/or cardia may stimulate the coronary artery and induce AMI in a patient with CAD [5]. CAD should likely be a relative contraindication for RF therapy in the treatment of refractory GERD.