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Introduction: Proactive esophageal cooling reduces injury during radiofrequency (RF) ablation of the left atrium (LA) for the treatment of atrial fibrillation (AF). New catheters are capable of higher wattage settings up to 90 W (very high-power short duration, vHPSD) for 4 s. Varying power and duration, however, does not eliminate the risk of thermal injury. Furthermore, alternative energy sources such as pulsed field ablation (PFA) also exhibit thermal effects, with clinical data showing esophageal temperatures up to 40.3°C. The ensoETM esophageal cooling device (Attune Medical, now a part of Haemonetics, Boston, MA, U.S.A.) is commercially available and FDA-cleared to reduce thermal injury to the esophagus during RF ablation for AF and is recommended in the 2024 expert consensus statement on catheter and surgical ablation of AF. Areas covered: This review summarizes growing evidence of esophageal cooling during high power RF ablation for AF treatment, including data relating to procedural efficacy, safety, and efficiency, and techniques to enhance operator success while providing directions for further research. Expert opinion: Proactive esophageal cooling reduces injury to the esophagus during high power RF ablation, and utilizing this approach may result in increased success in first-pass isolation, procedural efficiency, and long-term efficacy. Plain Language Summary: Atrial fibrillation is a condition that causes the heart to beat irregularly, which then may cause symptoms such as palpitations, shortness of breath, dizziness, and chest pain. Atrial fibrillation increases a person's risk of heart failure, dementia, stroke, and death. Radiofrequency catheter ablation is a frequently employed treatment option for atrial fibrillation. This is an elective procedure performed by specialty physicians called electrophysiologists. This treatment uses a thermal (heat) energy source to create scars in the heart that block the irregular or chaotic heartbeats. There are multiple approaches to delivering this energy, including delivering moderate energy over a specified time frame as well as delivering very high amounts of energy over a much-shortened time frame. Despite the approach used, one complication of this type of energy delivery is unintended injury to the esophagus, the organ behind the heart that passes food from the mouth to the stomach. In severe cases, this injury can develop into an atrioesophageal fistula, an abnormal connection between the heart and the esophagus, which can result in death. In this review, we discuss an available device that helps prevent this type of injury in both standard and higher energy delivery, without compromising the efficacy or efficiency of the procedure. [ABSTRACT FROM AUTHOR]

Diagnostic mediastinoscopy is a procedure with well-known serious complications: Hemorrhage, mediastinitis, pneumothorax and recurrent nerve damage. Esophageal perforation is a less known potentially life-threatening complication. Here the case of a young man with an iatrogenic esophageal perforation following a diagnostic mediastinoscopy is presented with a literary review of previously published cases. [ABSTRACT FROM AUTHOR]

Objective: While management protocols of pediatric esophageal foreign bodies (EFBs) are well‐delineated, resource utilization can be improved. This study's objectives were to explore hospital charges/costs for pediatric patients who present with EFBs and to identify patient risk factors associated with esophageal injury. Methods: A retrospective chart review of patients undergoing aerodigestive foreign body removal at a tertiary‐care children's hospital from 2018 to 2021 was conducted. Data collected included demographics, medical history, presenting symptoms, EFB type, surgical findings, and hospital visit charges/costs. Results: 203 patients were included. 178 of 203 (87.7%) patients were admitted prior to operation. Unwitnessed EFB ingestion (p < 0.001, OR = 15.1, 95% CI = 5.88–38.6), experiencing symptoms for longer than a week (p < 0.001, OR = 11.4, 95% CI = 3.66–38.6) and the following presenting symptoms increased the odds of esophageal injury: dysphagia (p = 0.04, OR = 2.45, 95% CI = 1.02–5.85), respiratory distress (p = 0.005, OR = 15.5, 95% CI = 2.09–181), coughing (p < 0.001, OR = 10.1, 95% CI = 3.73–28.2), decreased oral intake (p = 0.001, OR = 6.60, 95% CI = 2.49–17.7), fever (p = 0.001, OR = 5.52, 95% CI = 1.46–19.6), and congestion (p = 0.001, OR = 8.15, 95% CI = 2.42–27.3). None of the 51 asymptomatic patients had esophageal injury. The median total charges during the encounter was $20,808 (interquartile range: $18,636–$24,252), with operating room (OR) (median: $5,396; 28.2%) and inpatient admission (median: $5,520; 26.0%) contributing the greatest percentage. Conclusions: Asymptomatic patients with EFBs did not experience esophageal injury. The OR and inpatient observation accounted for the greatest percentage of the hospital charges. These results support developing a potential algorithm to triage asymptomatic patients to be managed on a same‐day outpatient basis to improve the value of care. Level of Evidence: 3 Laryngoscope, 134:4774–4782, 2024 [ABSTRACT FROM AUTHOR]

Diagnostic mediastinoscopy is a procedure with well-known serious complications: Hemorrhage, mediastinitis, pneumothorax and recurrent nerve damage. Esophageal perforation is a less known potentially life-threatening complication. Here the case of a young man with an iatrogenic esophageal perforation following a diagnostic mediastinoscopy is presented with a literary review of previously published cases.

Summary: A 74-year-old male patient was referred with signs of sepsis 5 days after having been diagnosed with a rib fracture following a fall out of bed. Novel hypodensities were visible on thoracic X‑rays and laboratory tests revealed elevated inflammatory parameters. Subsequently performed thoracic computed tomography (CT) scan showed burst fracture of the 3rd thoracic vertebra, posttraumatic esophageal rupture at the same level and mediastinitis. Furthermore, marked degenerative changes of the spinal column (diffuse idiopathic skeletal hyperostosis) were present. The patient underwent emergency thoracotomy and esophagectomy. Gastric pull-up with esophagogastrostomy was postponed for 3 days. After 14 days on the intensive care unit (ICU) and 12 days of i.v. antibiotics, the patient was transferred to the general ward and 7 weeks after trauma the patient was infection-free without difficulties in swallowing. Up to the latest follow-up 41 months following injury, several endoscopic dilations with a bougie due to constrictions at the anastomosis have been performed. Similar to previous cases in the literature, esophageal injury was diagnosed delayed, with the patient already having developed severe complications. This extremely seldom injury should be suspected in young patients following high-energy trauma, but also in older patients after low-energy trauma but known degenerative changes of the vertebral column. [ABSTRACT FROM AUTHOR]

Atrial fibrillation (AF) affects a significant proportion of older individuals, with prevalence rates of 3.8 ​% in those over 60 and 9.0 ​% in those over 80 years old, posing a considerable risk of stroke. Radiofrequency ablation (RFA) has emerged as a popular treatment option. However, RFA is not without risks, with esophageal injury being a notable complication, as illustrated by our case study of a 67-year-old patient who developed an atrial-esophageal fistula post-RFA. Timely diagnosis is imperative due to the rarity and severe consequences such as esophageal perforation. While treatment strategies remain somewhat uncertain, initial stenting has given way to surgical intervention for improved outcomes. Our study emphasizes the critical importance of vigilance, early identification, and a multidisciplinary approach in managing this challenging complication.

Introduction: Proactive esophageal cooling has been FDA cleared to reduce the likelihood of ablation‐related esophageal injury resulting from radiofrequency (RF) cardiac ablation procedures. Data suggest that procedure times for RF pulmonary vein isolation (PVI) also decrease when proactive esophageal cooling is employed instead of luminal esophageal temperature (LET) monitoring. Reduced procedure times may allow increased electrophysiology (EP) lab throughput. We aimed to quantify the change in EP lab throughput of PVI cases after the introduction of proactive esophageal cooling. Methods: EP lab throughput data were obtained from three EP groups. We then compared EP lab throughput over equal time frames at each site before (pre‐adoption) and after (post‐adoption) the adoption of proactive esophageal cooling. Results: Over the time frame of the study, a total of 2498 PVIs were performed over a combined 74 months, with cooling adopted in September 2021, November 2021, and March 2022 at each respective site. In the pre‐adoption time frame, 1026 PVIs were performed using a combination of LET monitoring with the addition of esophageal deviation when deemed necessary by the operator. In the post‐adoption time frame, 1472 PVIs were performed using exclusively proactive esophageal cooling, representing a mean 43% increase in throughput (p <.0001), despite the loss of two operators during the post‐adoption time frame. Conclusion: Adoption of proactive esophageal cooling during PVI ablation procedures is associated with a significant increase in EP lab throughput, even after a reduction in total number of operating physicians in the post‐adoption group. [ABSTRACT FROM AUTHOR]

Trauma-related esophageal injuries (TEIs) are a rare but highly lethal condition. The presentation of TEIs is very diverse depending on the location and mechanism of injury (blunt vs. penetrating), as well as the presence or absence of concurrent injuries. The aim of the present systematic review and meta-analysis is to delineate the clinical features impacting TEI management. A systematic review of the Medline, Embase, and web of science databases was undertaken for studies reporting on patients with TEIs. A random effects model was employed in the meta-analysis of aggregated data. Eleven studies, incorporating 4605 patients, were included, with a pooled mortality rate of 19% (95% confidence interval (CI) 13–25%). Penetrating injuries were 34% more likely to occur (RR 0.66, 95% CI 0.49–0.89, P  = 0.01), predominantly in the neck compartment. Surgery was employed in 53% of cases (95% CI 32–73%), with 68% of patients having associated injuries (95% CI 43–94%). In terms of choice of surgical repair technique, primary suture repair was most frequently reported, irrespective of injury location. Postoperative drainage was employed in 27% of the cases and was more common following repair of thoracic esophageal injuries. The estimated dependence on mechanical ventilation was 5.91 days (95% CI 5.1–6.72 days), while the length of stay in the intensive care unit averaged 7.89 days (95% CI 7.14–8.65 days). TEIs are uncommon injuries in trauma patients, associated with considerable mortality and morbidity. Open suture repair of ensuing esophageal defects is by large the most employed approach, while stenting may be indicated in carefully selected cases. [ABSTRACT FROM AUTHOR]

Background: Esophageal perforation and fistula formation are rare but serious complications following atrial fibrillation ablation. In this review article, we outline the incidence, pathophysiology, predictors, and preventative strategies of this dreaded complication. Methods: We conducted an electronic search in 10 databases/electronic search engines to access relevant publications. All articles reporting complications following atrial fibrillation ablation, including esophageal injury and fistula formation, were included for systematic review. Results: A total of 130 manuscripts were identified for the final review process. The overall incidence of esophageal injury following atrial fibrillation ablation was significantly higher with thermal ablation modalities (radiofrequency 5–40%, cryoballoon 3–25%, high-intensity focused ultrasound < 10%) as opposed to non-thermal ablation modalities (no cases reported to date). The incidence of esophageal perforation and fistula formation with the use of thermal ablation modalities is estimated to occur in less than 0.25% of all atrial fibrillation ablation procedures. The use of luminal esophageal temperature monitoring probe and mechanical esophageal deviation showed protective effect toward reducing the incidence of this complication. The prognosis is very poor for patients who develop atrioesophageal fistula, and the condition is rapidly fatal without surgical intervention. Conclusions: Esophageal perforation and fistula formation following atrial fibrillation ablation are rare complications with poor prognosis. Various strategies have been proposed to protect the esophagus and reduce the incidence of this fearful complication. Pulsed field ablation is a promising new ablation technology that may be the future answer toward reducing the incidence of esophageal complications. The recognition of risk factors and preventative strategies of esophageal injury, perforation, and fistula formation following atrial fibrillation ablation is essential to reduce the incidence of this dreaded complication (online abstract figure). [ABSTRACT FROM AUTHOR]

Introduction: High‐power short‐duration (HPSD) ablation at 50 W, guided by ablation index (AI) or lesion size index (LSI), and a 90 W/4 s very HSPD (vHPSD) setting are available for atrial fibrillation (AF) treatment. Yet, tissue temperatures during ablation with different catheters around venoatrial junction and collateral tissues remain unclear. Methods: In this porcine study, we surgically implanted thermocouples on the epicardium near the superior vena cava (SVC), right pulmonary vein, and esophagus close to the inferior vena cava. We then compared tissue temperatures during 50W‐HPSD guided by AI 400 or LSI 5.0, and 90 W/4 s‐vHPSD ablation using THERMOCOOL SMARTTOUCH SF (STSF), TactiCath ablation catheter, sensor enabled (TacthCath), and QDOT MICRO (Qmode and Qmode+ settings) catheters. Results: STSF produced the highest maximum tissue temperature (Tmax), followed by TactiCath, and QDOT MICRO in Qmode and Qmode+ (62.7 ± 12.5°C, 58.0 ± 10.1°C, 50.0 ± 12.1°C, and 49.2 ± 8.4°C, respectively; p =.005), achieving effective transmural lesions. Time to lethal tissue temperature ≥50°C (t−T ≥ 50°C) was fastest in Qmode+, followed by TacthCath, STSF, and Qmode (4.3 ± 2.5, 6.4 ± 1.9, 7.1 ± 2.8, and 7.7 ± 3.1 s, respectively; p <.001). The catheter tip‐to‐thermocouple distance for lethal temperature (indicating lesion depth) from receiver operating characteristic curve analysis was deepest in STSF at 5.2 mm, followed by Qmode at 4.3 mm, Qmode+ at 3.1 mm, and TactiCath at 2.8 mm. Ablation at the SVC near the phrenic nerve led to sudden injury at t−T ≥ 50°C in all four settings. The esophageal adventitia injury was least deep with Qmode+ ablation (0.4 ± 0.1 vs. 0.8 ± 0.4 mm for Qmode, 0.9 ± 0.3 mm for TactiCath, and 1.1 ± 0.5 mm for STSF, respectively; p =.005), correlating with Tmax. Conclusion: This study revealed distinct tissue temperature patterns during HSPD and vHPSD ablations with the three catheters, affecting lesion effectiveness and collateral damage based on Tmax and/or t−T ≥ 50°C. These findings provide key insights into the safety and efficacy of AF ablation with these four settings. [ABSTRACT FROM AUTHOR]

Background: Atrial esophageal fistula (AEF) is a lethal complication that can occur post atrial fibrillation (AF) ablation. Esophageal injury (EI) is likely to be the initial lesion leading to AEF. Endoscopic examination is the gold standard for a diagnosis of EI but extensive endoscopic screening is invasive and costly. This study was conducted to determine whether fecal calprotectin (Fcal), a marker of inflammation throughout the intestinal tract, may be associated with the existence of esophageal injury. Methods: This diagnostic study was conducted in a cohort of 166 patients with symptomatic AF undergoing radiofrequency catheter ablation from May 2020 to June 2021. Fcal tests were performed 1–7 days after ablation. All patients underwent endoscopic ultrasonography 1 or 2 days after ablation. Results: The levels of Fcal were significantly different between the EI and non‐EI groups (404.9 µg/g (IQR 129.6–723.6) vs. 40.4 µg/g (IQR 15.0–246.2), p <.001). Analysis of ROC curves revealed that a Fcal level of 125 µg/g might be the optimal cut‐off value for a diagnosis of EI, giving a 78.8% sensitivity and a 65.4% specificity. The negative predictive value of Fcal was 100% for ulcerated EI. Conclusions: The level of Fcal is associated with EI post AF catheter ablation. 125 µg/g might be the optimal cut‐off value for a diagnosis of EI. Negative Fcal could predict the absence of ulcerated EI, which could be considered a precursor to AEF. [ABSTRACT FROM AUTHOR]

What is the optimal management of spontaneous pneumomediastinum (SPM) and is there a risk of esophageal perforation in patients with SPM? We performed a retrospective case-control study of children through age 21, diagnosed with SPM in one hospital system over 10 years with the primary aim of describing the diagnostic workup, treatment patterns, and clinical outcomes. We hypothesized that SPM is a self-limited disease and is not associated with esophageal injury. Cases were identified using International Classification of Disease codes and excluded for trauma or severe infections. Median age was 16 years, 66% were male (n = 179). Chest radiography was performed in 97%, chest computed tomography (CT) in 33%, and esophagrams in 26%. Follow-up imaging showed resolution in 83% (mean = 17.2 days). SPM was not associated with esophageal perforation. We recommend avoiding CT scans and esophagrams unless there is discrete esophageal concern. Management of SPM should be guided by symptomatology. [ABSTRACT FROM AUTHOR]

Background: Pulsed‐field ablation (PFA) has emerged as a nonthermal energy source for cardiac ablation, with potential safety advantages over radiofrequency ablation (RFA) and cryoballoon ablation. Objective: To report the preclinical results of a novel hexaspline PFA catheter for pulmonary vein isolation (PVI), and to verify the influence of PFA on esophagus by comparing with RFA. Methods: This study included a total of 15 canines for the efficacy and safety study and four swine for the esophageal safety study. The 15 canines were divided into an acute cohort (n = 3), a 30‐day follow‐up cohort (n = 5) and a 90‐day follow‐up cohort (n = 7), PVI was performed with the novel hexaspline PFA ablation catheter. In the esophageal safety study, four swine were divided into PFA cohort (n = 2) and RFA cohort (n = 2), esophageal injury swine model was adopted, the esophagus was intubated with an esophageal balloon retractor, under fluoroscopy, the DV8 device was inflated with a mixture of saline and contrast and rotated to displace the esophagus rightward and anteriorly toward the ablation catheter in the inferior vena cava (IVC) and right inferior pulmonary vein (PV). Nine PFA applications were delivered at four locations on IVC and two locations on the right inferior PV in the PFA cohort, six RFA applications were delivered at each location in the RFA group. Histopathological analysis of all PVs, esophagus, IVC, and the adjacent lungs was performed. Results: Acute PV isolation was achieved in all 15 canines (100%), with energy delivery times of less than 3 min/animal. In the 30 and 90 days group, the overall success rates were 88.9% and 88.5% per PVs, respectively. Two right superior pulmonary veins (RSPVs) in the 30‐day group, two RSPVs and one left superior PV in the 90‐day group with recovered potentials. At follow‐up, gross pathological examination revealed the lesions around the PVs were continuous and transmural. Masson's trichrome staining revealed the myocardial cells in the PVs became fibrotic, but small arteries and nervous tissue were preserved. Results of swine esophageal injury model revealed the esophageal luminal surface was smooth and without evidence for esophageal injury in the PFA group, whereas obvious ulceration was detected on the esophagus tunica mucosa in the RFA group. Conclusion: In the chronic canine study, PFA‐based PVI were safe and effective with demonstrable sparing of nerves and venous tissue. Compared with RFA, there was also good evidence for safety of PFA, avoiding PV stenosis and esophageal injury. This preclinical study provided the scientific basis for the first‐in‐human endocardial PFA studies. [ABSTRACT FROM AUTHOR]

This article discusses the management of esophageal perforation in an elderly woman who had previously undergone therapeutic esophageal procedures for the treatment of esophageal carcinoma. Esophageal perforation is a serious complication associated with increased morbidity and mortality. The patient in this case was treated with esophageal stenting and parenteral nutrition, leading to a successful outcome. The article emphasizes the importance of prompt identification and management of esophageal perforation to prevent further complications. [Extracted from the article]

Esophageal perforation is a rare but well-known complication of anterior cervical spine surgery. We present a case report of 36-year-old male presenting with gradual painful left neck swelling, tenderness, fever, rigor, and chills, four months after anterior cervical spine surgery. After doing necessary investigations the patient was operated for pus drainage and esophageal perforation was also noticed during the surgery that was repaired along with hard ware removal. Later on due to wound complications the patient was referred to another higher center, where he was re-operated. After improvement he was received back in our hospital for follow-up management and then discharged after complete recovery. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Thermal injury to the esophagus during cryoablation for pulmonary vein isolation is a concern despite pre- and intraoperative assessment using conventional techniques. Navik 3D (APN Health, Waukesha, WI) is a novel 3D mapping system that can measure cryoballoon orientation and distance from the esophagus, both factors that correlate with esophageal injury. Purpose: This study assessed Navik 3D for cryoballoon localization and tried to assess the factors determining esophageal injury. Methods: Fifty consecutive patients undergoing cryoballoon ablation for pulmonary vein isolation, roof ablation, and posterior wall debulking were studied retrospectively. Results: Navik 3D was able to accurately compute the distance between the cryoballoon and the esophageal temperature probe in all cases, and also determine its orientation. Since the front half of the cryoballoon is the freezing surface, orientation toward (TOW) the esophagus as well as the actual distance were independent factors determining a decrease in esophageal temperature. Orientation TOW was associated with a lower esophageal temperature by 5.88°C (95% CI -7.20, -4.56; p<0.01) and a decrease in distance by 1 mm was associated with an esophageal temperature lowering of 0.05°C (95% CI 0.03, 0.06; p<0.01). Conclusion: Navik 3D allows accurate, real-time assessment of cryoballoon location and orientation in relation to the esophagus during ablation procedures; this may help prevent thermal injury. [ABSTRACT FROM AUTHOR]

Introduction: Neither the actual in vivo tissue temperatures reached with 90 W/4 s‐very high‐power short‐duration (vHPSD) ablation for atrial fibrillation nor the safety and efficacy profile have been fully elucidated. Methods: We conducted a porcine study (n = 15) in which, after right thoracotomy, we implanted 6–8 thermocouples epicardially in the superior vena cava, right pulmonary vein, and esophagus close to the inferior vena cava. We compared tissue temperatures close to a QDOT MICRO catheter, between during 90 W/4 s‐vHPSD ablation during ablation index (AI: target 400)‐guided 50 W‐HPSD ablation, both targeting a contact force of 8–15 g. Results: Maximum tissue temperature reached during 90 W/4 s‐vHPSD ablation did not differ significantly from that during 50 W‐HPSD ablation (49.2 ± 8.4°C vs. 50.0 ± 12.1°C; p =.69) and correlated inversely with distance between the catheter tip and the thermocouple, regardless of the power settings (r = −0.52 and r = −0.37). Lethal temperature (≥50°C) was best predicted at a catheter tip‐to‐thermocouple distance cut‐point of 3.13 and 4.27 mm, respectively. All lesions produced by 90 W/4 s‐vHPSD or 50 W‐HPSD ablation were transmural. Although there was no difference in the esophageal injury rate (50% vs. 66%, p =.80), the thermal lesion was significantly shallower with 90 W/4 s‐vHPSD ablation than with 50W‐HPSD ablation (381.3 ± 127.3 vs. 820.0 ± 426.1 μm from the esophageal adventitia; p =.039). Conclusion: Actual tissue temperatures reached with 90 W/4 s‐vHPSD ablation appear similar to those with AI‐guided 50 W‐HPSD ablation, with the distance between the catheter tip and target tissue being shorter for the former. Although both ablation settings may create transmural lesions in thin atrial tissues, any resulting esophageal thermal lesions appear shallower with 90 W/4 s‐vHPSD ablation. [ABSTRACT FROM AUTHOR]

Background: Neither the actual in vivo tissue temperatures reached with lesion size index (LSI)‐guided high‐power short‐duration (HPSD) ablation for atrial fibrillation nor the safety profile has been elucidated. Methods: We conducted a porcine study (n = 7) in which, after right thoracotomy, we implanted 6–8 thermocouples epicardially in the superior vena cava, right pulmonary vein, and esophagus close to the inferior vena cava. We compared tissue temperatures reached during 50 W‐HPSD ablation with those reached during standard (30 W) ablation, both targeting an LSI of 5.0 (5–15 g contact force). Results: Tmax (maximum tissue temperature when the thermocouple was located ≤5 mm from the catheter tip) reached during HPSD ablation was modestly higher than that reached during standard ablation (58.0 ± 10.1°C vs. 53.6 ± 9.2°C; p =.14) and peak tissue temperature correlated inversely with the distance between the catheter tip and the thermocouple, regardless of the power settings (HPSD: r = −0.63; standard: r = −0.66). Lethal temperature (≥50°C) reached 6.3 ± 1.8 s and 16.9 ± 16.1 s after the start of HPSD and standard ablation, respectively (p =.002), and it was best predicted at a catheter tip‐to‐thermocouple distance cut point of 2.8 and 5.3 mm, respectively. All lesions produced by HPSD ablation and by standard ablation were transmural. There was no difference between HPSD ablation and standard ablation in the esophageal injury rate (70% vs. 75%, p =.81), but the maximum distance from the esophageal adventitia to the injury site tended to be shorter (0.94 ± 0.29 mm vs. 1.40 ± 0.57 mm, respectively; p =.09). Conclusions: Actual tissue temperatures reached with LSI‐guided HPSD ablation appear to be modestly higher, with a shorter distance between the catheter tip and thermocouple achieving lethal temperature, than those reached with standard ablation. HPSD ablation lasting <6 s may help minimize lethal thermal injury to the esophagus lying at a close distance. [ABSTRACT FROM AUTHOR]

Compared with traditional ablation procedures, high power short duration ( HPSD) ablation significantly shortens the operation time, discharge time and fluoroscopy time, and reduces the incidence of periprocedural complications. HPSD ablation could not only maintain a high surgical success rate, but also would not increase the incidence of serious complications such as esophageal injury. It is characterized by high efficiency, high safety and low operation difficulty. In recent years, very high power short duration (vHPSD) ablation (90 W, 4 s) has been gradually introduced into clinical diagnosis and treatment, preliminarily showing its high safety and efficacy. With the development of new procedural methods and wide application of hybrid procedure, HPSD ablation may become the main means of rhythm control in patients with atrial fibrillation. This article reviews the clinical application and related progress of HPSD ablation. [ABSTRACT FROM AUTHOR]

Introduction: Esophageal thermal injury (ETI) is a well‐recognized complication of atrial fibrillation (AF) ablation. Previous studies have demonstrated that direct esophageal cooling reduces ETI during radiofrequency AF ablation. The purpose of this study was to evaluate the use of an esophageal warming device to prevent ETI during cryoballoon ablation (CBA) for AF. Methods: This prospective, double‐blinded study enrolled 42 patients with symptomatic AF undergoing CBA. Patients were randomized to the treatment group with esophageal warming (42°C) using recirculated water through a multilumen, silicone tube inserted into the esophagus (EnsoETM®; Attune Medical) (WRM) or the control group with a luminal single‐electrode esophageal temperature monitoring probe (LET). Patients underwent upper endoscopy esophagogastroduodenoscopy (EGD) the following day. ETI was classified into four grades. Results: Baseline patient characteristics were similar between groups. Procedural characteristics including number of freezes, total freeze time, early freeze terminations, coldest balloon temperature, procedure duration, posterior wall ablation, and proton pump inhibitor and transesophageal echocardiogram use before procedure were not different between groups. The EGD was completed in 40/42 patients. There was significantly more ETI in the WRM group compared to the LET group (n = 8 [38%] vs. n = 1 [5%], p = 0.02). All ETI lesions were grade 1 (erythema) or 2 (superficial ulceration). Total freeze time in the left inferior pulmonary vein was predictive of ETI (360 vs. 300 s, p = 0.03). Conclusion: Use of a luminal heat exchange tube for esophageal warming during CBA for AF was paradoxically associated with a higher risk of ETI. [ABSTRACT FROM AUTHOR]

Radiofrequency (RF) ablation of the left atrium of the heart is increasingly used to treat atrial fibrillation (AF). Unfortunately, inadvertent thermal injury to the esophagus can occur during this procedure, potentially creating an atrioesophageal fistula (AEF) which is 80% fatal. The ensoETM (Attune Medical, Chicago, IL), is an esophageal cooling device that has been shown to reduce thermal injury to the esophagus during RF ablation. This review summarizes growing evidence related to active esophageal cooling during RF ablation for the treatment of AF. The review presents data demonstrating improved outcomes related to patient safety and procedural efficiency and suggests directions for future research. The use of active esophageal cooling during RF ablation reduces esophageal injury, reduces or eliminates fluoroscopy requirements, reduces procedure duration and post-operative pain, and increases long-term freedom from arrhythmia. These effects in turn increase patient same-day discharge rates, decrease operator cognitive load, and reduce cost. These findings are likely to further accelerate the adoption of active esophageal cooling. Atrial fibrillation is a condition in which the heart beats irregularly, causing symptoms such as palpitations, dizziness, shortness of breath, and chest pain. Atrial fibrillation increases the risk of stroke, heart failure, dementia, and death. One treatment for atrial fibrillation is a procedure called a catheter ablation. This procedure is minimally invasive and is performed by a specialized cardiologist, called an electrophysiologist. The electrophysiologist, or operator, uses an energy source, such as radiofrequency energy (radio waves), to stop erratic electrical signals from traveling through the heart. One complication of the catheter ablation is an inadvertent injury to the esophagus, the organ that passes food from the mouth to the stomach. If the injury is severe, it may develop into an atrioesophageal fistula, which often results in death. In this review, a new technology is described that helps prevent this type of injury and can provide additional benefits for the patient, operator, and hospital. [ABSTRACT FROM AUTHOR]

Background: Active esophageal cooling is increasingly utilized as an alternative to luminal esophageal temperature (LET) monitoring for protection against thermal injury during pulmonary vein isolation (PVI) when treating atrial fibrillation (AF). Published data demonstrate the efficacy of active cooling in reducing thermal injury, but impacts on procedural efficiency are not as well characterized. LET monitoring compels pauses in ablation due to heat stacking and temperature overheating alarms that in turn delay progress of the PVI procedure, whereas active esophageal cooling allows avoidance of this phenomenon. Our objective was to measure the change in PVI procedure duration after implementation of active esophageal cooling as a protective measure against esophageal injury. Methods: We performed a retrospective review under IRB approval of patients with AF undergoing PVI between January 2018 and February 2020. For each patient, we recorded age, gender, and total procedure time. We then compared procedure times before and after the implementation of active esophageal cooling as a replacement for LET monitoring. Results: A total of 373 patients received PVI over the study period. LET monitoring using a multi-sensor probe was performed in 198 patients, and active esophageal cooling using a dedicated device was performed in 175 patients. Patient characteristics did not significantly differ between groups (mean age of 67 years, and gender 37.4% female). Mean procedure time was 146 ± 51 min in the LET-monitored patients, and 110 ± 39 min in the actively cooled patients, representing a reduction of 36 min, or 24.7% of total procedure time (p <.001). Median procedure time was 141 [IQR 104 to 174] min in the LET-monitored patients and 100 [IQR 84 to 122] min in the actively cooled patients, for a reduction of 41 min, or 29.1% of total procedure time (p <.001). Conclusions: Implementation of active esophageal cooling for protection against esophageal injury during PVI was associated with a significantly large reduction in procedure duration. [ABSTRACT FROM AUTHOR]

Background: High pharyngo-esophageal strictures following corrosive ingestion continue to pose a challenge to the surgeon, particularly in the developing world. With the advancements and increased experience with microsurgical techniques, free jejunal flaps offer a viable reconstruction option in patients with high corrosive strictures with previous failed reconstruction. We review our experience with free jejunal flap in three cases with high pharyngo-esophageal stricture following corrosive ingestion, with previous failed reconstruction. Materials and methods: A total of three patients underwent salvage free jejunal flap after failed reconstruction for high pharyngo-esophageal strictures following corrosive acid ingestion. All the three patients developed anastomotic leak and subsequent stricture, two following a pharyngo-gastric anastomosis and one following a pharyngo-colic anastomosis. The strictured segment was bridged using a free jejunal graft with microvascular anastomosis to the lingual artery and common facial vein. All patients were followed-up at regular intervals. Results and conclusions: The strictured pharyngeal anastomotic segment was successfully reconstructed with free jejunal flap in all the three patients. Patients were able to take food orally and maintain nutrition without the need of jejunostomy feeding. On long-term follow-up (median: 5 years), there was no recurrence of dysphagia and all the patients had good health-related quality of life. [ABSTRACT FROM AUTHOR]

A male patient developed hematemesis and chest pain after severe vomiting. Gastroscopy showed a linear hematoma from the esophageal entrance to the cardia. Enhanced CT of the esophagus revealed a high-density shadow in the middle of the esophagus. Severe vomiting can lead to esophageal injury and esophageal hematoma. As this condition mimics critical symptoms of myocardial infarction and aortic dissection, clinicians must remain vigilant. This case emphasizes the importance of recognizing acute submucosal bleeding in the digestive tract, aiding in clinical diagnosis and treatment., Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Lei et al.)

Objective: High power short duration (HPSD) ablation strategy is proposed to be more effective than low power long duration (LPLD) for radiofrequency ablation of atrial fibrillation. Although small trials abound, data from a large cohort are lacking. This meta-analysis compares all the existing studies comparing these two approaches to evaluate perceived advantages of one over the other. Methods: A systematic search of PubMed, EMBASE, and Cochrane databases identified studies comparing HPSD to LPLD ablation. All the analyses used the random-effects model. Results: Ablation settings varied widely across 20 studies comprising 2,136 patients who underwent HPSD and 1,753 patients who underwent LPLD. The pooled incidence of atrial arrhythmia recurrence after HPSD ablation was 20% [95% confidence interval (CI): 0.16 0.25; I2=88%]. Atrial arrhythmia recurrences were significantly less frequent with HPSD ablation (incidence risk ratio=0.66; 95% CI: 0.49–0.88; I2=72%; p=0.004). Procedural, fluoroscopy, and ablation times were significantly shorter with HPSD ablation. First-pass pulmonary vein isolations (PVIs) were significantly more [odds ratio (OR)=2.94; 95% CI: 1.50–5.77; I2=89%; p=0.002), and acute pulmonary vein reconnections (PVRs) were significantly lesser (OR=0.41; 95% CI: 0.28–0.62; I2=62%; p

Abstract Background Pill-induced esophageal injury may cause severe complications if not diagnosed in a timely fashion. The condition is under-recognized and under-reported, and some patients present with atypical clinical or endoscopic features mimicking other common conditions. If the diagnosis is missed the patient will continue to take the offending drug, potentially worsening the illness. We present a case in which acute coronary syndrome was the initial working diagnosis leading to a delay in diagnosis of doxycycline-induced esophageal injury. The patient developed multiple esophageal ulcers and hemorrhage. Case presentation A 50-year-old male driver with a history of hypertension and dyslipidemia was brought to the emergency department with complaints of severe retrosternal chest pain, vomiting, diaphoresis and syncope. On initial evaluation, acute coronary syndrome was considered due to the clinical presentation and history of cardiovascular risk factors. Electrocardiogram and serum troponins were normal. On the second day of his admission, the patient developed odynophagia and bloody vomitus. Esophagogastroduodenoscopy revealed extensive esophageal ulcerations with hemorrhage. The patient was taking Doxycycline capsules for an acute febrile illness. Doxycycline is the oral medication most commonly reported to cause esophageal injury. Doxycycline was discontinued, and the patient was treated with intravenous omeprazole and oral antacid suspension. The patient improved, was discharged after 6 days of hospitalization, and reported resolution of all symptoms at an outpatient follow-up visit 3 weeks later. Conclusion Medication-induced esophageal injury can present with atypical symptoms mimicking acute coronary syndrome. This condition should be included in the initial differential diagnosis of patients presenting with acute chest pain, especially those taking oral medications known to cause esophageal injury.

Background: Esophageal thermal lesion (ETL) is a complication of radiofrequency ablation for atrial fibrillation (RFAF). To prospectively compare the incidence of ETL, we used two linear, five‐ and three‐sensor esophageal thermal monitoring catheters (ETMC5 and ETMC3). We also evaluated the predictors of ETL. Methods: Patients receiving their first RFAF (n = 106) were randomized into two groups, ETMC5 (n = 52) and ETMC3 (n = 54). Ablation was followed by esophagogastroduodenoscopy within 3 days. Results: Esophageal thermal lesion was detected in 7/106 (6.6%) patients (ETMC5: 3/52 [5.8%] vs. ETMC3: 4/54 [7.4%]; p = 1.0). The maximum temperature and number of measurements > 39.0°C did not differ between the groups (ETMC5: 40.5°C and 5.4 vs. ETMC3: 40.6°C and 4.9; p =.83 and p =.58, respectively). In ETMC5 group, the catheter had to be moved significantly less often (0.12 vs. 0.42; p =.0014) and fluoroscopy time was significantly shorter (79.2 min vs. 101.7 min; p =.0038) compared with ECMC3 group. The total number of ablations in ETMC5 group was significantly greater (50.2 vs. 37.7; p =.030) and ablation time was significantly longer (52.1 min vs. 40.1 min; p =.0039). Only body mass index (BMI) was significantly different between patients with and without ETL (21.4 ± 2.5 vs. 24.3 ± 3.4; p =.022). Conclusions: The incidence of ETL was comparable between ETMC5 and ETMC3 groups; however, fluoroscopy time, total ablation time, and total number of ablations differed significantly. Lower BMI may increase the risk of developing ETL. [ABSTRACT FROM AUTHOR]

Abstract Background Traumatic esophageal injury leads to severe complications such as mediastinitis, pyothorax, and tracheoesophageal fistula. Although prompt diagnosis and treatment are required, there are no established protocols to guide diagnosis or treatment. In particular, thoracic esophageal injury tends to be diagnosed later than cervical esophageal injury because it has few specific symptoms. We report a case of thoracic esophageal injury caused by a cervical stab wound; the patient was stabbed with a sharp blade. Case presentation A 74-year-old woman was attacked with a knife while sleeping at home. The patient was taken to the emergency room with an injury localized to the left section of her neck. She was suspected of a left jugular vein and recurrent laryngeal nerve injury from cervical hematoma and hoarseness. On the day following the injury, computed tomography revealed a thoracic esophageal injury. Emergency surgery was performed for an esophageal perforation and mediastinal abscesses. Although delayed diagnosis resulted in suture failure, the patient was able to resume oral intake of food a month later following enteral feeding with a gastrostomy. Esophageal injuries due to sharp trauma are rare, and most are cervical esophageal injuries. There are very few reports on thoracic esophageal injuries. Conclusions The possibility of thoracic esophageal injury should always be considered when dealing with neck stab wounds, particularly those caused by an attack.

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. [ABSTRACT FROM AUTHOR]

ObjectiveAccidental ingestion of button batteries (BB), usually occurred in children and infants, will rapidly erode the esophagus and result in severe complications, even death. It has been recommended that treatment of this emergent accident as soon as possible with drinking of pH-neutralizing viscous solutions such as honey and sucralfate before surgical removal can mitigate the esophageal injury. Recently, we reported that the electric insulating solutions such as edible oils could mitigate tissue damage in BB-exposed esophageal segments. In this study, we compared the protective effect of kitchen oil with honey or sucralfate, the recommended pH-neutralizing beverages, and with their mixture on esophageal injury caused by BB ingestion in pig esophageal segments and in living piglets.MethodsEffect of olive oil irrigations was compared to that of honey or sucralfate irrigations in the BB-damaged esophageal segments freshly collected from the local abattoir and in live Bama miniature piglets with the proximal esophagus exposed to BB for 60 min. Also, the effect of olive oil and honey mixture (MOH) irrigations was assessed in live animals. The BB voltage was recorded before insertion and after its removal. Gross and histological analysis of the esophageal injury was performed after BB exposure in segmented fresh esophagus and 7 days after BB exposure in live animals, respectively.ResultsOlive oil irrigations demonstrated better protective effect against BB-induced esophageal damage, compared to honey or sucralfate for BB-induced esophageal damage in vitro. But in vivo study showed that olive oil alone exacerbated esophageal injury because all esophagi irrigated with olive oil perforated. Surprisingly, irrigations with the MOH showed considerable protective effect for BB-induced esophageal damage in live animals, significantly better than irrigations with honey alone. The MOH decreased BB discharge, reduced area of surface injury, attenuated injured depth of esophageal wall thickness, and downed the mucosal injury index in comparison to using honey alone.ConclusionIrrigations with olive oil alone couldn’t prevent the BB discharge and is harmful for BB ingestion before surgical removal. However, mixed with honey, olive oil very effectively prevents the BB discharging and produces better esophageal protection than honey.

The authors discuss an in vivo porcine study, published in the issue, in which epicardially implanted thermocouples were used to investigate tissue temperatures close to the Q-DOT Micro catheter during 90 W/4s lesions, very high-power short duration (vHPSD), compared to ablation index guided 50 W HPSD lesions both targeting a contact force or 8-15 g. Topics include vHPSD lesions analyzed in the study, the design of the Q-DOT Micro ablation catheter and finding on the lethal tissue temperature.

Objective: To model the evolution of peak temperature and volume of damaged esophagus during and after radiofrequency (RF) ablation using low power‐moderate duration (LPMD) versus high power‐short duration (HPSD) or very high power‐very short duration (VHPVSD) settings. Methods: An in silico simulation model of RF ablation accounting for left atrial wall thickness, nearby organs and tissues, as well as catheter contact force. The model used the Arrhenius equation to derive a thermal damage model and estimate the volume of esophageal damage over time during and after RF application under conditions of LPMD (30 W, 20 s), HPSD (50 W, 6 s), and VHPVSD (90 W, 4 s). Results: There was a close correlation between maximum peak temperature after RF application and volume of esophageal damage, with highest correlation (R2 = 0.97) and highest volume of esophageal injury in the LPMD group. A greater increase in peak temperature and greater relative increase in esophageal injury volume in the HPSD (240%) and VHPSD (270%) simulations occurred after RF termination. Increased endocardial to esophageal thickness was associated with a longer time to maximum peak temperature (R2 > 0.92), especially in the HPSD/VHPVSD simulations, and no esophageal injury was seen when the distances were >4.5 mm for LPMD or >3.5 mm for HPSD. Conclusion: LPMD is associated with a larger total volume of esophageal damage due to the greater total RF energy delivery. HPSD and VHPVSD shows significant thermal latency (resulting from conductive tissue heating after RF termination), suggesting a requirement for fewer esophageal temperature cutoffs during ablation. [ABSTRACT FROM AUTHOR]

Background: More than 3,000 cases of accidental ingestion of coin-shaped lithium batteries (CSLBs) have been reported in the United States. Battery ingestion can cause serious injury and even death. Prior reports have indicated that complications often occur two or more hours after ingestion. However, to date, the temporal changes in esophageal damage remain unclear. To address this knowledge gap, we examined the histological features associated with these temporal changes., Methods: Six piglets were used as models. After laparotomy and thoracotomy, three CSLBs were inserted into the esophagus of each pig. The esophagi were removed for histological examination at 0.5, 1, 2, 4, 6, and 8 hours. The consumed capacities of the batteries were measured after removal., Results: Mucosal damage began at the margins of batteries, gradually spreading to the centers of the negative pole. At 0.5 hours after implantation, although necrosis at the limbus had reached the muscle layer, it became more extensive with time. At six hours, the full-thickness wall was damaged in all areas of the negative pole. The consumed capacity increased markedly after six hours, at which point holes opened in the outer case on the positive pole of the battery with observed electrolyte leakage. The consumed capacity was correlated with the amount of alkaline hydroxide ions., Conclusion: Our study revealed changes over time in injury site and depth. Although early diagnosis and treatment are necessary, managing batteries to avoid complications is also important. Additionally, developing safer batteries is warranted., Competing Interests: Human subjects: All authors have confirmed that this study did not involve human participants or tissue. Animal subjects: Compliance with the animal experiment regulations of The Jikei University School of Medicine and in accordance with the animal experiment protocol. Issued protocol number 2016-026. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Ohashi et al.)

Endoscopic retrograde cholangiopancreatography (ERCP) is a frequently performed procedure in the management of hepatobiliary diseases that can be conducted as a therapeutic or diagnostic procedure. Also, it can be done with or without sphincterotomy and stent insertion. Hemorrhage is one of the most common post-ERCP complications, which can be presented as late as 10 days. Other complications include post-ERCP pancreatitis and perforation. Gut perforation during ERCP is rare but often lethal. Here we present a 35-year-old female who was admitted to the hospital through the ER as a case of obstructive jaundice with common bile duct (CBD) stone. ERCP with stent insertion was performed for the patient to relieve the obstruction; however, intra-procedural retroperitoneal perforation was encountered., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Albugami et al.)

Anterior cervical discectomy and fusion (ACDF) is a commonly performed procedure. One of its most feared complications is esophageal injury (EI). There is no standard approach on how to treat these injuries. TachoSil ® (Corza Medical GmbH, Düsseldorf, Germany) is a fibrinogen-containing patch that has been used in various surgical areas. Here, we present a 68-year-old male patient who was diagnosed with an EI with secondary surgical site infection following a three-level ACDF (C4/5, C5/6, and C6/7). Initially, the patient underwent incision and drainage (I&D) of the surgical site abscess, primary repair of the esophageal tear, and esophageal catheter placement to create a controlled esophagocutaneous fistula. Postoperatively, he was diagnosed with a leak and underwent a second I&D procedure. The primary repair of the EI was augmented with a TachoSil patch, and the patient was started on glycopyrrolate. The site of EI was well-sealed with no re-leaks, and the patient was discharged after he had completed a course of intravenous (IV) antibiotics and had been on parenteral nutrition for a total of 40 days. This case shows that the use of TachoSil to augment the repair of ACDF-associated EI, and glycopyrrolate to decrease salivation could decrease the risk of leak and enhance the healing process. This is an observation that needs to be scrutinized in future studies., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Alashkar et al.)

The authors reflect on the efforts to maximize outcomes and mitigate esophageal injuries during atrial fibrillation ablation as guided by the Ablation Index (AI). Other topics include the methods that were developed to guide titration of radiofrequency (RF) energy delivery, the use of the CLOSE protocol to optimize and standardize ablation delivery during pulmonary vein isolation (PVI), and how the high-power-short-duration (HSPD) ablation can enhance ablation safety.

Background: Actual in vivo tissue temperatures and the safety profile during high‐power short‐duration (HPSD) ablation of atrial fibrillation have not been clarified. Methods: We conducted an animal study in which, after a right thoracotomy, we implanted 6–8 thermocouples epicardially in the superior vena cava, right pulmonary vein, and esophagus close to the inferior vena cava. We recorded tissue temperatures during a 50 W‐HPSD ablation and 30 W‐standard ablation targeting an ablation index (AI) of 400 (5–15 g contact force). Results: Maximum tissue temperatures reached with HSPD ablation were significantly higher than that reached with standard ablation (62.7 ± 12.5 vs. 52.7 ± 11.4°C, p = 0.033) and correlated inversely with the distance between the catheter tip and thermocouple, regardless of the power settings (HPSD: r = −0.71; standard: r = −0.64). Achievement of lethal temperatures (≥50°C) was within 7.6 ± 3.6 and 12.1 ± 4.1 s after HPSD and standard ablation, respectively (p = 0.003), and was best predicted at cutoff points of 5.2 and 4.4 mm, respectively. All HPSD ablation lesions were transmural, but 19.2% of the standard ablation lesions were not (p = 0.011). There was no difference between HPSD and standard ablation regarding the esophageal injury rate (30% vs. 33.3%, p > 0.99), with the injury appearing to be related to the short distance from the catheter tip. Conclusions: Actual tissue temperatures reached with AI‐guided HPSD ablation appeared to be higher with a greater distance between the catheter tip and target tissue than those with standard ablation. HPSD ablation for <7 s may help prevent collateral tissue injury when ablating within a close distance. [ABSTRACT FROM AUTHOR]