Severe Esophageal Complications Following Atrial Fibrillation Ablation: Should We Still Be Concerned?

Atrial fibrillation (AF) ablation has been increasingly employed as an effective strategy for rhythm control, leading to a reduction in arrhythmia burden, improved quality of life, and, in selected cases, decreased mortality. However, as an invasive procedure, it carries inherent risks. Severe esophageal complications-such as esophageal perforation or atrioesophageal fistula- though rare (with an incidence ranging from 0.025% to 0.113%), are associated with significant morbidity and mortality. Multiple risk factors for esophageal injury have been identified, including both patient-related and procedure-related characteristics. To mitigate these risks during radiofrequency (RF) ablation, several preventive measures have been adopted, including the use of contact force catheters, high-power short-duration energy applications, and protective strategies such as esophageal temperature monitoring, displacement devices, and cooling techniques. Deep esophageal lesions detected through surveillance endoscopy are considered potential precursors to more serious complications and, therefore, warrant close attention. Enhanced monitoring of patients with such lesions may be crucial for enabling early diagnosis and timely intervention to prevent the progression to more severe complications. While pulsed field ablation therapy, which poses a lower risk to the esophagus and other surrounding structures, is not yet widely available, the implementation of robust monitoring strategies can significantly improve clinical outcomes and enhance patient safety in the context of RF AF ablation.