Esophageal injury after very high-power short-duration pulmonary vein isolation assessed by late gadolinium enhancement MRI

Background Esophageal injury is a recognized complication of radiofrequency (RF) pulmonary vein isolation (PVI). Very high-power, short-duration (vHPSD) ablation produces shallower lesions, potentially limiting esophageal damage. However, the temporal evolution of esophageal injury after vHPSD remains unexplored. Late gadolinium enhancement cardiac MRI (LGE-CMR) provides a noninvasive method to assess esophageal tissue changes over time. Purpose To evaluate esophageal injury over time using LGE-CMR, comparing vHPSD and conventional ablation index (AI)-guided ablation, and to assess the impact of esophageal anatomical position and posterior wall reconnection requiring additional RF applications. Methods Patients with AF (n=59,61±8 years) underwent primo RF PVI using AI (30/40W,n=19), or vHPSD (90W/4s,n=40) ablation without esophageal temperature monitoring. LGE-CMR was performed at baseline, <72 hours, and 3 months post-PVI. Esophageal signal intensity (SI) was measured from manually drawn regions of interest in sagittal and axial planes at the mid-left atrial (LA) level. SI values were averaged and normalized to a reference region of presumed healthy esophagus below the LA to obtain SI ratio (SIRESO). Anterior and posterior esophageal LGE were assessed over time, by ablation modality, esophageal location, and, in the vHPSD group, by occurrence of posterior reconnection requiring touch-up ablation at 35-50W. Results In the overall cohort, anterior SIRESO increased significantly within 72 hours post-PVI and, although reduced at 3 months, remained elevated compared with 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). Patients with the esophagus adjacent to a pulmonary vein (PV) (n=48) had higher anterior SIRESO at early and 3-month follow-up than those with an inter-PV position (n=11). Similar temporal patterns were observed with vHPSD and AI-guided ablation, although partial SIRESO reduction at 3 months occurred only in the vHPSD group. Within the vHPSD group (n=40), patients with acute posterior reconnection (n=13) had higher anterior SIRESO at 3 months than those without reconnection and subsequent touch-up ablation. Posterior SIRESO showed no significant change over time. Conclusion This study demonstrates that RF PVI is associated with an increase in anterior esophageal LGE early post-PVI that persists at 3 months, potentially indicating irreversible injury. Only in the vHPSD group, partial resolution of esophageal LGE was observed. Esophageal enhancement was higher when the esophagus was adjacent to a PV and in patients with acute posterior wall reconnection requiring additional touch-up applications. These findings provide the first quantitative, longitudinal, noninvasive assessment of esophageal injury after PVI, defining modality- and location-specific patterns, while clinical relevance requires further validation.Fig 1.Esophageal LGE post-PVIFig 2.