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.