Pulsed Field Versus Radiofrequency Ablation of Atrial Fibrillation: Esophageal Lesions and Suspected Gastroparesis

BACKGROUND: Esophageal mucosal injury and gastroparesis are clinically important complications of radiofrequency ablation (RFA) of atrial fibrillation (AF). Pulsed-field ablation (PFA) is a non-thermal modality that may spare these complications due to its myocardial tissue selectivity. OBJECTIVES: We aimed to compare the incidence of endoscopically detected esophageal lesions (EDELs) and suspected gastroparesis between RFA and PFA as the primary endpoints. Secondary endpoints included perioperative complications, procedural parameters, and 365-day clinical outcomes. METHODS: Between July 2023 and July 2025, patients undergoing a first-time AF ablation with RFA or PFA were enrolled. RFA was performed using either a QDOT MICRO catheter (Biosense Webster, Inc., Irvine, CA, USA) or a TactiFlex Ablation Catheter, Sensor Enabled (Abbott, Abbott Park, IL, USA), while PFA was performed using the FARAPULSE system or the PulseSelect system. All patients underwent upper gastrointestinal endoscopy on the day after ablation. An EDEL was defined as esophageal erythema, erosion, ulcer, or atrio-esophageal fistula. Suspected gastroparesis was defined as gastric food residue after > 12 h of overnight fasting. Clinical follow-up was performed with 12-lead or Holter electrocardiography. RESULTS: A total of 84 patients were included (RFA: n = 43; PFA: n = 41). Esophageal erosion was observed in 2 patients in the RFA group (4.7%) and in none in the PFA group (p = 0.49). Suspected gastroparesis occurred in 15 patients treated with RFA (34.9%) and in none treated with PFA (P<0.001). All patients were asymptomatic during endoscopy. No other procedural complications were observed in either group. The total procedure time was significantly shorter with PFA (158.5 ± 40.8 vs. 193.8 ± 38.3 min, p < 0.001), while the fluoroscopy time was longer. At 365 days, atrial arrhythmia recurrence rates were comparable between the two groups (p = 0.47). CONCLUSIONS: In this single-center cohort, PFA was associated with a significantly lower incidence of suspected gastroparesis than RFA, and no EDELs were observed in the PFA group. PFA may reduce gastrointestinal injury associated with AF ablation. Further studies are needed to confirm these findings and clarify their clinical significance.