Esophageal heating is not limited to left atrial ablation.

A 36-year-old man with a history of cardiac arrest status post dual-chamber implantable cardioverter-defibrillator underwent pulmonary vein (PV) isolation for paroxysmal atrial fibril-lation (AF). During the first procedure, esophageal temperature rises (≥38.5ºC) were noted during posterior left atrial radiofre-quency ablation (red dots; Figure 1A), but PV isolation was eventually achieved. However, the patient developed recurrent AF and underwent a redo procedure under general anesthesia. Two transseptal punctures were performed under fluoroscopy and intracardiac echo (AcuNav; Siemens, Mountain View, CA) guidance. A long 8-Fr (SL-1; St Jude Medical, St Paul, MN) and a deflectable sheath (Agilis; St Jude Medical) were advanced to the left atrium (LA). In both procedures, a multisensor esopha-geal temperature probe (Circa S-Cath; Circa Scientific, Park City, UT) was inserted into the esophagus to the level of the PVs and used to record the intraluminal esophageal temperature continuously. All 4 PVs were found to be persistently isolated. The level of PV isolation was extended to include the posterior wall using an externally irrigated 3.5-mm tip quadripolar ablation catheter (Thermocool; Biosense Webster Inc, Diamond Bar, CA). Esophageal temperature rises were seen again during ablation of roof and posterior lines (red dots; Figure 1D). Burst atrial pacing–induced sustained AF and subsequent electric cardioversion were followed by premature atrial complexes that triggered AF (Figure 1B). These were mapped to the posterior right atrial (RA) wall near the inferior vena cava. During ablation (25 W) in this region (Figure 1C), multiple esophageal temperature rises >38.5ºC were noted. The trigger disappeared with ablation, and nothing further could be induced even with isoproterenol infusion (20 μg/min). The patient had no recurrent AF off of antiarrhythmic drugs at 6 months of follow-up. Discussion Atrioesophageal fistula is a feared complication of AF abla-tion and has been reported after ablation of the posterior LA. Despite its low incidence (0.03–0.1%), this complication can be devastating, with a resultant mortality >75%. 3 In addition to limiting the power and duration of radiofrequency applications on posterior LA, real-time luminal esophageal temperature (LET) monitoring with a probe has been shown to minimize the risk of esophageal injury when using a strategy of cessation of radiofrequency ablation once a prespecified rise in LET is observed. 4 Although esophageal temperature rises are of common occurrence during posterior LA ablation, LET monitoring is rarely performed when ablating the posterior RA wall. As demonstrated fortuitously in this case, significant esopha-geal temperature (≈39ºC) rises can be …