Shielding the Achilles Heel of Atrial Fibrillation Ablation

Collateral damage to esophagus with ablative therapies for atrial fibrillation (AF) remains a major concern with percutaneous catheter based therapies. Endoscopically documented thermal injuries to the esophageal mucosa such as ulcerations or hemorrhages are seen in a significant percentage of patients undergoing AF ablation. [1,2] The reporting of occurrence of a fatal left atrio-oesophageal fistula (LAEF) with circumferential pulmonary vein isolation in 2004, led to an explosion of innovations and strategies to protect the esophagus during transmural posterior left atrial lesions. The use of low energy lesions in the posterior wall, introduction of a temperature probe in the esophagus, use of proton pump inhibitors, pre and intra procedure imaging and alternative sources of ablation have all contributed to this endeavor. Clinical applications of each of these strategies have shown that none of them are infallible in completely attenuating the vulnerability of esophagus during pulmonary vein isolation.