The development of an atrioesophageal fistula after catheter ablation of atrial fibrillation (AF) is fortunately a rare but almost always lethal complication, representing the second most frequent cause of death after pulmonary vein isolation (PVI) following cardiac tamponade (prevalence 0.04%, mortality 11%). Risk factors for this rare event are not yet established. The prevalence of esophageal and mediastinal injuries after PVI varies considerably in different studies and is possibly associated with the formation of an atrioesophageal fistula. Schmidt et al reported a very high prevalence of 47% esophageal injury diagnosed by conventional endoscopy, whereas other studies reported lower rates of esophageal changes. We were not able to show mucosal esophageal injury in a series of 29 patients, yet structural changes of the mediastinum diagnosed by endosonography occurred in 27% of the patients. Avoidance strategies in daily practice are diverse: monitoring the course of the esophagus using various imaging modalities, measuring the luminal esophageal temperature, reducing the power while ablating at the posterior wall of the left atrium, and performing the ablation procedure under conscious sedation rather than general anesthesia to observe pain as a surrogate for esophageal injury.
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