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Updated: May 10, 2026

Cooling or Warming the Esophagus to Reduce Esophageal Injury During Left Atrial Ablation in the Treatment of Atrial Fibrillation

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Published on: March 15, 2020

Minimizing Atrioesophageal Fistula Risk After AF Ablation: Risk Factors, Prevention, and Emerging Mini-Thermal

Muhammed Ibrahim Erbay¹, Esedullah Yağlı¹, Tasha Phillips-Wilson²

¹Cerrahpasa Faculty of Medicine, Istanbul Cerrahpasa University, Istanbul, Turkiye.

Pacing and Clinical Electrophysiology : PACE

|September 3, 2025

Summary

This summary is machine-generated.

Pulsed-field ablation (PFA) shows promise in reducing atrial esophageal fistula (AEF) risk during atrial fibrillation (AF) ablation by minimizing thermal injury. However, long-term safety and potential collateral damage require further investigation.

Keywords:

atrial esophageal fistula atrial fibrillation ablation catheter ablation complications cryo‐balloon ablation esophageal thermal injury pulsed‐field ablation radiofrequency ablation

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Area of Science:

Cardiology
Electrophysiology
Medical Technology

Background:

Atrial esophageal fistula (AEF) is a rare, life-threatening complication of atrial fibrillation (AF) ablation using radiofrequency (RF) and cryo-balloon (CB) techniques.
Thermal injury to the esophagus is the primary cause of AEF, necessitating risk mitigation strategies.

Purpose of the Study:

To review current knowledge on AEF and esophageal thermal injuries.
To discuss the potential of pulsed-field ablation (PFA) as a novel, minimally thermal modality for AF ablation.
To evaluate the safety and efficacy of PFA in reducing AEF risk.

Main Methods:

Review of current literature on AEF, thermal injuries, and PFA.
Analysis of meta-analyses and recent studies on PFA outcomes.
Discussion of PFA's mechanism (irreversible electroporation) and its impact on tissue selectivity.

Main Results:

PFA induces irreversible electroporation, significantly reducing thermal injury and demonstrating improved safety profiles.
Recent meta-analyses report zero esophageal injury and AEF cases with PFA.
PFA integration with 3D mapping enhances precision and lowers radiation exposure.

Conclusions:

PFA may reduce the risk of AEF in catheter ablation for AF due to its non-thermal mechanism.
While early PFA outcomes are encouraging, long-term AEF risk requires further study.
Caution is advised with PFA in patients with hemolytic anemia or renal dysfunction due to potential collateral damage like hemolysis and coronary vasospasms.