No single esophageal protection strategy completely eliminates thermal injury risk during radiofrequency AF ablation; mechanical esophageal deviation combined with luminal esophageal temperature monitoring had the most favorable ranking, but confidence in the evidence is limited by small trials and reliance on surrogate outcomes.
The systematic review included 25 randomized trials (~2,500 patients), of which 12 trials (1,077 patients) formed the connected network for the network meta-analysis.
Mechanical esophageal deviation combined with luminal esophageal temperature monitoring (LET) had the most favorable point estimate versus no dedicated protection and the highest treatment ranking, but the network estimate was statistically imprecise.
Visualization-guided strategies also showed a favorable but non-significant point estimate for reducing EDEL.
LET alone and active cooling did not demonstrate significant reductions in EDEL.
In direct comparison, mechanical deviation plus LET significantly reduced odds of EDEL compared with single-sensor LET.
Higher-power versus standard-power radiofrequency ablation was not significantly associated with EDEL.
The network showed moderate heterogeneity without significant evidence of inconsistency or publication bias.
Confidence in the evidence is limited by small trial sizes and use of a surrogate outcome, and rare catastrophic complications were not assessed.
Radiofrequency ablation for atrial fibrillation can sometimes burn the esophagus, which lies right behind the heart. Mild injuries are seen in up to 10-15% of patients on endoscopy, and a rare but often deadly complication, an atrio-esophageal fistula, can follow. This study pooled data from randomized trials to compare different ways of protecting the esophagus, such as physically moving it aside, monitoring its temperature, cooling it, or using visualization to guide ablation. The approach of physically deviating the esophagus while also monitoring temperature ranked best, and in a direct comparison it cut the odds of esophageal lesions substantially compared with a single temperature sensor. Visualization-guided approaches also looked promising. Temperature monitoring alone and active cooling did not clearly reduce injury. Using higher-power ablation instead of standard power did not significantly change the rate of esophageal lesions. However, the overall comparison against no protection had wide uncertainty, so the results are not conclusive. This research suggests that no current method fully eliminates esophageal injury risk. The trials were small and measured lesions seen on endoscopy rather than serious outcomes such as fistula, which are too rare to detect in such studies. Larger, more modern trials are needed to confirm which strategies truly improve patient safety.
Ramezani A, Kian N, Sharafi A, Yousefimoghaddam F, Khezrpour A, Ghaffari Jolfayi A, et al.. (2026). Comparative efficacy of esophageal protection strategies during radiofrequency atrial fibrillation ablation: a systematic review and network meta-analysis of randomized trials.. BMC cardiovascular disorders. https://doi.org/10.1186/s12872-026-06836-z