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Ablation Approaches and Imaging Modalities to Lower Risk of Atrioesophageal Injury During Catheter Ablation for Atrial Fibrillation


Purpose of Review

Atrioesophageal fistula (AEF) is a rare yet catastrophic complication of atrial fibrillation (AF) ablation. Limited data exists on measures to prevent AEF. This review focuses on AF ablation approaches, esophageal protective strategies, and imaging modalities that can be utilized to reduce the risk of AEF.

Recent Findings

AEF has been reported to occur in less than 0.1% of AF ablation cases. Left untreated, it is associated with 100% mortality. Diagnosing AEF requires a high index of suspicion as symptoms are usually nonspecific. Several AF ablation techniques might reduce the risk of esophageal thermal injury (ETI): high-power short-duration radiofrequency ablation, implementation of time-to-isolation ablation strategy with cryoablation, and electroporation. Various esophageal protective approaches have been investigated. Although luminal esophageal temperature monitoring is widely used, data on its efficacy is conflicting. Esophageal cooling and esophageal deviation strategies have been shown to be effective in reducing the risk of ETI. Late gadolinium enhancement magnetic resonance imaging (LGE-MRI) is a noninvasive imaging modality that seems to have high sensitivity for detecting and quantifying the degree of ETI.


Variable approaches have been reported to reduce the risk of esophageal injury. These approaches focus mainly on modulating ablation parameters and esophageal luminal temperature. Imaging modalities such as LGE-MRI can potentially identify early signs of ETI. Electroporation is a promising ablation technique that exhibits high tissue selectivity and can potentially reduce risk of esophageal injury.

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Fig. 1


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

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Correspondence to Mihail G. Chelu.

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Marashly, Q., Chelu, M.G. Ablation Approaches and Imaging Modalities to Lower Risk of Atrioesophageal Injury During Catheter Ablation for Atrial Fibrillation. Curr Cardiovasc Risk Rep 14, 1 (2020).

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  • Atrioesophageal fistula
  • Esophageal thermal injury
  • Catheter ablation
  • Esophageal deviation
  • Esophageal luminal temperature
  • Electroporation
  • Late gadolinium enhancement magnetic resonance imaging (LGE-MRI)