September 12, 2026Journal of Interventional Cardiac Electrophysiology
Participant-reported chest pain and gastric esophageal reflux disease following protective esophageal cooling during radiofrequency ablation for atrial fibrillation – the EVERCOOL-AF study
Key result
Bilateral first-pass isolation in AF ablation with esophageal cooling is linked to less post-ablation chest pain.
- n=295
Why the study?
Active esophageal cooling reduces thermal injury risk during AF ablation but may not reduce GERD symptoms, and factors associated with post-ablation GERD and chest pain despite cooling remain unclear.
Study Design
Type
Observational (n=295)
Structured PICO
P
Population
295 participants with paroxysmal or persistent atrial fibrillation undergoing radiofrequency ablation with active esophageal cooling, assessed at 7-14 days post-procedure.
E
Exposure
Radiofrequency ablation with active esophageal cooling
O
Outcome
Post-ablation gastroesophageal reflux disease (GERD) symptoms (GERDQ score ≥ 8) and chest pain at 7-14 days post-procedurepatient reported
Despite active esophageal cooling during AF ablation, post-procedural chest pain and GERD remain common and are associated with specific patient and procedural factors such as younger age and lack of bilateral first-pass isolation.
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Our lab has published studies showing a 30% reduction in procedure time and a 14% improvement in long-term efficacy when using ensoETM. This important multicentre study will help us to further quantify effects in a wider range of practice across the USA.”
“I've been using proactive oesophageal cooling for over two years now, and have been quite pleased with the safety and procedural efficiency that it offers, which in turn has increased our lab throughput to enable the treatment of more patients. I expect this new study will further quantify our experience.”
DJDr. Jose Osorioelectrophysiologist
“This evaluation will help us confirm the benefits of oesophageal cooling beyond safety alone, including shorter procedure times, reduced fluoroscopy requirements, greater hospital savings, and improved long-term freedom from arrhythmia.”
Implication
Post-ablation chest pain remains common despite esophageal cooling; leaves open whether bilateral first-pass isolation reduces symptoms pending prospective trials.
Abstract
Background Gastroesophageal reflux disease (GERD) and chest pain are common complications following catheter ablation for atrial fibrillation (AF), often attributed to esophageal thermal injury. Active esophageal cooling reduces thermal injury risk but may not reduce GERD symptoms. Factors associated with these complications, despite esophageal cooling, remain unclear. Our objective was to identify participant and procedural characteristics associated with post-ablation GERD and (CP) in AF participants undergoing radiofrequency ablation (RFA) with esophageal cooling. Methods Participants undergoing RFA with esophageal cooling for paroxysmal or persistent AF completed a standardized questionnaire. GERD symptoms were assessed with GERDQ (score ≥ 8 high probability of GERD) at 7–14 days post-procedure. Chest pain was queried separately. Associations with demographic and procedural variables were evaluated. Results There were 295 out of a maximum of 312 participants completing post-ablation questionnaires that underwent esophageal cooling, 44 (14.9%) met criteria for GERD ≥ 8 and 71 (24.1%) reported CP. The anterior maximum power was significantly lower in participants with GERD compared to those without (50.0 vs. 54.0 ± 14.0 W, p = 0.020). Participants reporting CP were younger (64.5 ± 9.3 vs. 67.5 ± 10.2 years, p = 0.026) and had higher mean ejection fraction (57.1 ± 6.6% vs. 53.1 ± 10.2%, p = 0.001). Chest pain was less common if bilateral first-pass isolation was achieved (59.2% vs. 72.6%, p = 0.033). Conclusion In participants undergoing AF ablation with active esophageal cooling, younger age, higher ejection fraction and lack of bilateral first-pass isolation were associated with post-ablation CP. These findings suggest that despite esophageal protection, both procedural and participant-specific factors may contribute to symptom development.
Discussion
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Cite This Study
Silverstein et al. (2026) conducted an observational in Atrial fibrillation (n=295). Radiofrequency ablation with active esophageal cooling was evaluated on Post-ablation GERD (GERDQ score ≥ 8) and chest pain. Among patients undergoing AF ablation with esophageal cooling, post-ablation chest pain occurred in 24.1% and was less common when bilateral first-pass isolation was achieved (59.2% vs 72.6%, p=0.033).