Esophageal endoscopic findings after pulmonary vein and posterior wall isolation using pulsed field ablation: results from the Eso-PFA study

Abstract Aims Substrate modification, including left atrial posterior wall isolation (LAPWI), may be performed in AF patients undergoing catheter ablation. Pulsed field ablation (PFA) may protect adjacent structures like the esophagus. However, data on esophageal safety following PFA-guided LAPWI are limited. The aim is to evaluate esophageal safety during post-procedural esophagogastroduodenoscopy (EGD) and follow-up after PFA-guided LAPWI in patients with AF. Methods and results This prospective observational study included consecutive AF patients who underwent PFA-guided LAPWI and post-procedural EGD (the day after PFA), with follow-up for long-term safety. In total, 106 consecutive patients (94% persistent AF, 66 ± 14 years, 70% male, 2 ± 1 prior ablation procedures) were included. The total median procedure time was 78 [interquartile range (IQR): 49–111] min, and a mean of 50 ± 19 and 21 ± 9 PFA applications were delivered per patient and on the LAPW, respectively. One suspected transient ischaemic attack and three minor complications occurred. No thermal, ablation-related esophageal lesions were observed in any patient during EGD. Non-ablation-related incidental gastrointestinal findings were detected in 70% of patients. During a median follow-up of 606 days [IQR: 212–922], no additional esophageal adverse events were reported. Atrial arrhythmia recurrences occurred in 34% (36/106) patients (including antiarrhythmic drugs). Left atrial posterior wall isolation durability was 78% (11/14). Conclusion In this real-world cohort, PFA-guided LAPWI was safe for the esophagus, with no thermal injury observed in post-procedural endoscopy. These results further support PFA as a promising technology for AF ablation with a favourable esophageal safety profile. The role of post-ablation proton pump inhibitors in a population where incidental gastrointestinal findings were common needs further exploration.