Contemporary Approaches And Treatment Strategies To Avoid Esophageal Injury During Atrial Fibrillation Ablation

The purpose of this review is to summarize the clinical data regarding methods of avoiding and protecting the esophagus from injury during ablation of atrial fibrillation (AF).

For >15 years, the primary method to avoid esophageal injury has been monitoring luminal esophageal temperature (LET), even though numerous studies report several limitations to this technique. For the past several years, two devices have been used to deviate the esophagus so to increase the distance of the esophagus from the ablation energy source and thus avoid esophageal injury. However, these devices are not FDA approved. In 2023, however, two devices did achieve FDA approval for reduction of ablation-related esophageal injury. The first device uses vacuum suction and deviation and thus moves an entire segment either to the right or left, as well as incorporating LET monitoring. The second device is inserted into the esophagus, inflated and then uses a closed loop system to pump cool distilled water at 4°C.

For every AF ablation procedure, a primary concern for electrophysiologists is to avoid esophageal injury, yet despite focused attention and advances in technology, the rate of atrioesophageal fistula and major morbidity related to esophageal injury continues. When considering the expanding number of AF ablations (>900,000 worldwide), even a low percentage of complications represents a large number of patients impacted by this complication. With the development of approved esophageal protection devices, it is prudent to implement a standardized method to avoid esophageal injury which provides greater confidence of safe AF ablation.