[Catheter ablation-induced esophageal complications]

Catheter ablation-induced atrioesophageal fistula (AEF) is one of the most devastating complications of catheter ablation in atrial fibrillation patients and is associated with extraordinarily high morbidity and mortality. Mucosal ulceration, erosion and erythema are milder variants of esophageal injury. Esophageal ulceration is an indicator for increased risk of progression to AEF. In case of clinical suspicion of esophageal perforation with or without fistula a computed tomography with contrast-medium is obligatory to exclude a cardiac fistula before performing esophageal endoscopy. Published strategies to prevent esophageal injury are the use of esophageal temperature probes, mechanical esophagus deviating devices and active esophageal cooling devices. Furthermore, many different strategies were tested to reduce the risk of esophageal injury by modifying ablation techniques and RF ablation parameters in order to limit ablation lesion depth at left atrial posterior wall.Confirmation of an AEF requires urgent cardiac surgery. A conservative or endoscopic approach without surgical intervention is associated with excessively high mortality in case of AEF according to current literature.In case of esophageal perforation without fistula different endoscopic strategies or conservative approaches in combination with a high vigilance for potential progression to fistula have been suggested.A timely, multi-disciplinary and consequently performed standard approach is crucial for a successful management of clinically relevant ablation-induced esophageal complications including esophageal perforation and AEF.The risk of AEF after atrial fibrillation ablation using pulsed field ablation (PFA) techniques seems to be extremely low. Histological esophageal alterations after PFA ablation at left atrial posterior wall have been recently described in an animal experimental study. However, despite the fact that no case of AEF after PFA has been published so far, every new PFA ablation catheter and PFA ablation protocol should also be tested for safety regarding potential esophageal injury.