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Background Luminal esophageal temperature (LET) monitoring is not associated with reduced esophageal injury following pulmonary vein isolation (PVI). Objective Detailed analysis of (the temporal and spatial gradients of) LET measurements may better predict the risk for esophageal injury. Methods Between January 2020 and December 2021, LET maxima, duration of LET rise above baseline, and area under the LET curve (AUC) were calculated offline and correlated with (endoscopy and endoscopic ultrasound detected) esophageal injury (i.e., mucosal esophageal lesions [ELs], periesophageal edema, and gastric motility disorders) following PVI using moderate‐power moderate‐duration (MPMD [25–30 W/25–30s]) and high‐power short‐duration (HPSD [50 W/13s]) radiofrequency (RF) settings. Results 63 patients (69 ± 9 years old, 32 male, 51 MPMD and 12 HPSD) were studied. The esophageal injury was frequent (40% in both groups), mucosal ELs were more common with MPMD, and edema was frequently observed following HPSD. RF‐duration, total RF‐energy at the left atrial (LA) posterior wall, and distance between LA and esophagus were not different between patients with/without esophageal injury. In contrast, to LET and LET duration above baseline, AUC was the best predictor and significantly increased in patients with esophageal injury (3422 vs. 2444 K.s). Conclusion For both ablation strategies, AUC of the LET curves best predicted esophageal injury. HPSD is associated with similar rates of esophageal injury when (mostly subclinical) periesophageal alterations (that are of unclear clinical relevance) are included. Whether integration of these calculated LET parameters is useful to prevent esophageal injury remains to be seen.

Introduction Safety of pulmonary vein isolation (PVI) has been established in clinical studies. However, despite prevention efforts the incidence of damage to (peri)‐esophageal tissue has not decreased, and the pathophysiology is incompletely understood. Damage to vagal nerve branches may be involved in lesion progression to atrio‐esophageal fistula. Using electrogastrography, we assessed the incidence of periesophageal vagal nerve injury (VNI) following atrial fibrillation ablation and its association with procedural parameters and endoscopic results. Methods Patients were studied using electrogastrography, endoscopy, and endoscopic ultrasound before and after cryoballoon (CB) or radiofrequency (RF) PVI. The incidence of ablation‐induced neuropathic pattern (indicating VNI) in pre‐ and postprocedural electrogastrography was assessed and correlated with endoscopic results and ablation data. Results Between February 2021 und January 2022, 85 patients (67 ± 10 years, 53% male) were included, 33 were treated with CB and 52 with RF (38 with moderate power moderate duration [25–30 W] and 14 with high power short duration [50 W]). Ablation‐induced VNI was detected in 27/85 patients independent of the energy form. Patients with VNI more frequently had postprocedural endoscopically detected pathology (8% mucosal esophageal lesions, 36% periesophageal edema, 33% food retention) but there was incomplete overlap. Pre‐existing esophagitis increased the likelihood of VNI. Ablation data and esophageal temperature data did not predict VNI. Conclusion PVI‐induced VNI is quite common and independent of ablation energy source. VNI is part of (peri)‐esophageal damage and only partially overlaps with endoscopic findings. VNI‐associated acidic reflux may be involved in the complex pathophysiology of esophageal lesion progression to fistula.

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