Evaluation of esophageal injury after very high-power short-duration pulmonary vein isolation using late gadolinium enhancement MRI
N Van Pouderoijen, E L C H Stokman, L H G A Hopman, M B M Hofman, M J Mulder, M J B Kemme, M J W Gotte, C P AllaartAbstract
Background
Esophageal injury is a recognized complication of radiofrequency (RF) ablation for pulmonary vein isolation (PVI). Very high-power, short-duration (vHPSD) ablation may mitigate this risk by creating shallower lesions through enhanced resistive heating and limited conductive spread, potentially minimizing the depth of tissue damage. However, the temporal evolution of esophageal injury following PVI using vHPSD remains poorly understood. Late gadolinium enhancement cardiac MRI (LGE-CMR) offers a noninvasive approach to evaluate esophageal tissue.
Purpose
This study aimed to evaluate the temporal evolution of esophageal injury after vHPSD ablation compared with conventional ablation index (AI)-guided ablation in atrial fibrillation (AF) patients, using LGE-CMR before, early, and 3 months after PVI.
Methods
Patients with AF (n=59, 61±8 years) underwent RF PVI using AI (30/40W, AI≥400 anterior and ≥550 posterior, n=19), or vHPSD (90W/s, n=40) ablation. LGE-CMR was performed at baseline, <72 hours, and 3 months post-PVI in sinus rhythm. Esophageal signal intensity (SI) was measured from manually drawn regions of interest in transverse and sagittal planes at the mid-left atrial (LA) level, with slice selection guided by ablation scar on the 3-month scan. SI values were averaged and normalized to a reference region of presumed healthy esophagus below the LA to obtain SI ratio (SIReso). The anterior and posterior esophageal walls were evaluated separately over time and compared across ablation modalities.
Results
No esophageal complications or symptoms suggestive of injury were reported in any patient. In the total cohort, anterior SIReso significantly increased within 72 hours post-PVI compared to baseline and although it declined at 3 months relative to the early post-ablation stage, it remained significantly elevated compared to baseline (1.06 [0.95–1.18] to 1.36 [1.13–1.57] to 1.21 [1.03–1.40], all p<0.01). Posterior SIReso did not differ significantly across time points. Similar patterns in SIReso were observed across both vHPSD and AI ablation, although partial resolution at 3 months occurred only in the vHPSD group. Changes in anterior and posterior SIReso over time (ΔSIReso) did not differ between vHPSD and AI patients.
Conclusion
This study shows that RF PVI leads to increased anterior esophageal LGE early post-PVI, which persists at 3 months compared to baseline. While the temporal patterns in the vHPSD group were similar to those observed with AI ablation, partial resolution at 3 months only occurred in the vHPSD group. Despite this reduction, both modalities exhibited persistently elevated esophageal LGE compared with baseline, potentially indicating irreversible esophageal injury. These findings suggest that RF ablation primarily affects the anterior esophagus, likely due to its proximity to the posterior LA wall, with both vHPSD and conventional RF showing comparable levels of esophageal injury over time.Figure.Esophageal LGE post-PVITable.Esophageal LGE post-PVI changes