Erbay Muhammed Ibrahim, Yağlı Esedullah, Phillips-Wilson Tasha, Çeviker Arda, Huang Henry D, Marine Joseph E, Yalın Kıvanç
Cerrahpasa Faculty of Medicine, Istanbul Cerrahpasa University, Istanbul, Turkiye.
University of Michigan School of Public Health, Ann Arbor, Michigan, USA.
Pacing Clin Electrophysiol. 2025 Sep 2. doi: 10.1111/pace.70037.
Atrial esophageal fistula (AEF) is a rare but life-threatening complication of atrial fibrillation (AF) ablation, linked to thermal injuries by conventional radiofrequency (RF) and cryo-balloon (CB) ablation techniques. AEF risk can be mitigated by considering several measures such as tailored power settings of ablation technique, mechanical displacement of esophagus, esophageal cooling, and alternative ablative techniques and energy sources. We review the current knowledge regarding AEF and esophageal thermal injuries as well as discussing the current research regarding a novel none-to-minimally thermal, myocardial tissue-selective modality known as pulsed-field ablation (PFA) which may mitigate such risks. By inducing irreversible electroporation, PFA reduces thermal injury and demonstrates improved safety profiles, as evidenced by recent meta-analyses reporting zero esophageal injury and AEF cases. Additionally, the integration of 3D mapping systems with PFA has enhanced its procedural precision and accuracy while lowering the radiation exposure. Despite these advances, challenges such as standardizing anesthesia protocols and tailoring energy settings remain. Our review suggests that PFA may reduce the risk of AEF from catheter ablation of AF. While early outcomes of PFA are encouraging, it is important to recognize that preliminary data may not always be predictive of long-term AEF formation risk, as demonstrated by earlier experiences with CB ablation. Although PFA may reduce the risk of any aberrant thermal injuries, recent studies report significant increase in collateral damage including hemolysis, exaggerated troponin leak and coronary vasospasms. PFA should be used with caution in patients with hemolytic anemia or renal dysfunction, as they may experience more pronounced effects. Future long-term outcome studies should provide more information on possible adverse outcomes with PFA as well as tailoring the power settings of PFA.
心房食管瘘（AEF）是心房颤动（AF）消融术一种罕见但危及生命的并发症，与传统射频（RF）和冷冻球囊（CB）消融技术导致的热损伤有关。通过考虑多种措施，如调整消融技术的功率设置、食管的机械移位、食管冷却以及替代消融技术和能量源等，可以降低AEF风险。我们回顾了关于AEF和食管热损伤的现有知识，并讨论了目前有关一种新型非热至微热的心肌组织选择性消融方式——脉冲场消融（PFA）的研究，该消融方式可能降低此类风险。通过诱导不可逆电穿孔，PFA减少了热损伤并显示出更好的安全性，最近的荟萃分析报告显示食管损伤和AEF病例为零，证明了这一点。此外，3D映射系统与PFA的整合提高了手术的精确性和准确性，同时降低了辐射暴露。尽管取得了这些进展，但仍存在诸如规范麻醉方案和调整能量设置等挑战。我们的综述表明，PFA可能降低房颤导管消融术导致AEF的风险。虽然PFA的早期结果令人鼓舞，但重要的是要认识到，初步数据可能并不总是能预测长期AEF形成风险，早期CB消融的经验就证明了这一点。尽管PFA可能降低任何异常热损伤的风险，但最近的研究报告称，包括溶血、肌钙蛋白过度泄漏和冠状动脉痉挛在内的 collateral 损伤显著增加。对于患有溶血性贫血或肾功能不全的患者，应谨慎使用PFA，因为他们可能会出现更明显的影响。未来的长期结局研究应提供更多关于PFA可能的不良结局以及调整PFA功率设置的信息。 （注：原文中“collateral damage”直译为“附带损害”，这里结合语境意译为“ collateral 损伤”，因为不清楚原文具体所指的专业术语准确含义，可能存在不准确情况，需结合更专业背景知识进一步确认）
