Skip to main content

Incidence and clinical relevance of upper gastrointestinal pathology during preprocedural endoscopy in patients undergoing pulmonary vein isolation



Reflux-induced esophagitis might facilitate ablation-induced esophageal lesions (ELs) following pulmonary vein isolation (PVI), and these may progress to atrio-esophageal fistula (AEF). In contrast, preexisting ELs are not prone to progression but may affect procedure planning.


To study the incidence of preexisting esophageal and upper gastrointestinal (UGI) pathology in patients undergoing PVI, and the relation to ablation-induced ELs.


From 08/2018 to 09/2021, consecutive patients undergoing (radiofrequency [RF] or cryoballoon [CB]) PVI were examined by esophagogastroscopy (EGD) before and following ablation. Postprocedural endoscopic ultrasound (EUS) was added in 2021.


412 patients (median age 67.5 [IQR 61.3–75.0] years, 56.1% male) were studied. Preprocedural EGD showed abnormalities in 226/399 patients, 15% in the lower third of the esophagus. Half (99/226) were relevant for PVI, 13 procedures were postponed, 6 due to pathological EGD results.

A third of the patients with new esophageal injury following ablation had preexisting esophagitis which was associated with a trend for a higher incidence of ELs after RF ablation (12.5 vs. 6.9%, p = 0.232), and a six- and two-fold higher rate of food retention after CB-PVI (28.6 vs. 4.5%, p = 0.008) and RF ablation (8.3 vs. 4.4%, p = 0.279), respectively.


(1) EGD before PVI showed UGI abnormalities in > 50% of patients, one-fourth of these relevant for PVI. (2) Esophageal inflammation was associated with a higher incidence of post-ablation (peri)-esophageal injury. Whether having this information before ablation is able to reduce ELs or AEF remains to be shown.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2



Atrial fibrillation


Atrio-esophageal fistula






Esophageal lesion


Endoscopic ultrasound


Gastro-esophageal reflux disease


Interquartile range


Left atrium/left atrial


Left atrial posterior wall


Luminal esophageal temperature


Odds ratio




Pulmonary vein isolation




Upper gastrointestinal




  1. Knopp H, Halm U, Lamberts R, Knigge I, Zachaus M, Sommer P et al (2014) Incidental and ablation-induced findings during upper gastrointestinal endoscopy in patients after ablation of atrial fibrillation: a retrospective study of 425 patients. Heart Rhythm 11(4):574–578.

    CAS  Article  PubMed  Google Scholar 

  2. Marrouche NF, Guenther J, Segerson NM, Daccarett M, Rittger H, Marschang H et al (2007) Randomized comparison between open irrigation technology and intracardiac-echo-guided energy delivery for pulmonary vein antrum isolation: procedural parameters, outcomes, and the effect on esophageal injury. J Cardiovasc Electrophysiol 18(6):583–588.

    Article  PubMed  Google Scholar 

  3. Kapur S, Barbhaiya C, Deneke T, Michaud GF (2017) Esophageal injury and atrioesophageal fistula caused by ablation for atrial fibrillation. Circulation 136(13):1247–1255.

    Article  PubMed  Google Scholar 

  4. Zawada AE, Moszak M, Skrzypczak D, Grzymislawski M (2018) Gastrointestinal complications in patients with diabetes mellitus. Adv Clin Exp Med 27(4):567–572.

    Article  PubMed  Google Scholar 

  5. Schoonderwoerd BA, Smit MD, Pen L, Van Gelder IC (2008) New risk factors for atrial fibrillation: causes of “not-so-lone atrial fibrillation.” Europace 10(6):668–673.

    Article  PubMed  Google Scholar 

  6. Miyasaka Y, Barnes ME, Gersh BJ, Cha SS, Bailey KR, Abhayaratna WP et al (2006) Secular trends in incidence of atrial fibrillation in Olmsted County, Minnesota, 1980 to 2000, and implications on the projections for future prevalence. Circulation 114(2):119–125.

    Article  PubMed  Google Scholar 

  7. Furnkranz A, Bordignon S, Schmidt B, Bohmig M, Bohmer MC, Bode F et al (2013) Luminal esophageal temperature predicts esophageal lesions after second-generation cryoballoon pulmonary vein isolation. Heart Rhythm 10(6):789–793.

    Article  PubMed  Google Scholar 

  8. Halm U, Gaspar T, Zachaus M, Sack S, Arya A, Piorkowski C et al (2010) Thermal esophageal lesions after radiofrequency catheter ablation of left atrial arrhythmias. Am J Gastroenterol 105(3):551–556.

    Article  PubMed  Google Scholar 

  9. Zellerhoff S, Ullerich H, Lenze F, Meister T, Wasmer K, Monnig G et al (2010) Damage to the esophagus after atrial fibrillation ablation: just the tip of the iceberg? High prevalence of mediastinal changes diagnosed by endosonography. Circ Arrhythm Electrophysiol 3(2):155–159.

    Article  PubMed  Google Scholar 

  10. Sami SS, Ragunath K (2013) The Los Angeles classification of gastroesophageal reflux disease. Video J Encyclopedia GI Endosc 1(1):103–104.

    Article  Google Scholar 

  11. Cordes F, Ellermann C, Dechering DG, Frommeyer G, Kochhauser S, Lange PS et al (2021) Pre-procedural proton pump inhibition is associated with fewer peri-oesophageal lesions after cryoballoon pulmonary vein isolation. Sci Rep 11(1):4728.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  12. Kadado AJ, Akar JG, Hummel JP (2019) Luminal esophageal temperature monitoring to reduce esophageal thermal injury during catheter ablation for atrial fibrillation: a review. Trends Cardiovasc Med 29(5):264–271.

    Article  PubMed  Google Scholar 

  13. Meininghaus DG, Blembel K, Waniek C, Kruells-Muench J, Ernst H, Kleemann T et al (2021) Temperature Monitoring and temperature-driven irrigated radiofrequency energy titration do not prevent thermally-induced esophageal lesions in pulmonary vein isolation a randomized study controlled by esophagoscopy before and after catheter ablation. Heart Rhythm.

    Article  Google Scholar 

  14. Jacobs V, May HT, Crandall BG, Ballantyne B, Chisum B, Johnson D et al (2018) Vagus nerve injury symptoms after catheter ablation for atrial fibrillation. Pacing Clin Electrophysiol 41(4):389–395.

    Article  PubMed  Google Scholar 

  15. Martinek M, Hassanein S, Bencsik G, Aichinger J, Schoefl R, Bachl A et al (2009) Acute development of gastroesophageal reflux after radiofrequency catheter ablation of atrial fibrillation. Heart Rhythm 6(10):1457–1462.

    Article  PubMed  Google Scholar 

  16. Hilberath JN, Oakes DA, Shernan SK, Bulwer BE, D’Ambra MN, Eltzschig HK (2010) Safety of transesophageal echocardiography. J Am Soc Echocardiogr 23(11):1115–1127.

    Article  PubMed  Google Scholar 

  17. Pasricha PJ, Fleischer DE, Kalloo AN (1994) Endoscopic perforations of the upper digestive tract: a review of their pathogenesis, prevention, and management. Gastroenterology 106(3):787–802.

    CAS  Article  PubMed  Google Scholar 

  18. Sarairah SY, Woodbury B, Methachittiphan N, Tregoning DM, Sridhar AR, Akoum N (2019) Esophageal thermal injury following cryoballoon ablation for atrial fibrillation. JACC Clin Electrophysiol.

    Article  PubMed  Google Scholar 

  19. Cordes F, Ellermann C, Dechering DG, Frommeyer G, Kochhauser S, Lange PS et al (2019) Time-to-isolation-guided cryoballoon ablation reduces oesophageal and mediastinal alterations detected by endoscopic ultrasound: results of the MADE-PVI trial. Europace 21(9):1325–1333.

    Article  PubMed  Google Scholar 

  20. Ayoub T, El Hajjar AH, Singh Sidhu GD, Bhatnagar A, Zhang Y, Mekhael M et al (2022) Esophageal temperature during atrial fibrillation ablation poorly predicts esophageal injury: an observational study. Heart Rhythm O2.

    Article  Google Scholar 

  21. Singh SM, d’Avila A, Singh SK, Stelzer P, Saad EB, Skanes A et al (2013) Clinical outcomes after repair of left atrial esophageal fistulas occurring after atrial fibrillation ablation procedures. Heart Rhythm 10(11):1591–1597.

    Article  PubMed  Google Scholar 

  22. Han J, Good E, Morady F, Oral H (2004) Images in cardiovascular medicine. Esophageal migration during left atrial catheter ablation for atrial fibrillation. Circulation 110(24):e528.

    Article  PubMed  Google Scholar 

  23. Cochet H, Nakatani Y, Sridi-Cheniti S, Cheniti G, Ramirez FD, Nakashima T et al (2021) Pulsed field ablation selectively spares the oesophagus during pulmonary vein isolation for atrial fibrillation. Europace.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Levy I, Gralnek IM (2016) Complications of diagnostic colonoscopy, upper endoscopy, and enteroscopy. Best Pract Res Clin Gastroenterol 30(5):705–718.

    Article  PubMed  Google Scholar 

Download references


RF was supported by the German Federal Ministry of Education and Research (Medical Informatics Initiative, 01ZZ1802A-Z, AB).

Author information

Authors and Affiliations



All authors contributed to the study conception, conduct and design. Material preparation, data collection and analysis were performed by Dirk Grosse Meininghaus and Robert Freund. The first draft of the manuscript was written by Dirk Grosse Meininghaus and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Dirk Grosse Meininghaus.

Ethics declarations

Conflict of interest

JCG is a consultant for Abbott, Medtronic, Biotronik, Boston Scientific, Daiichi Sankyo, Pfizer, and has received speaker fees from AstraZeneca, Bayer, Boehringer Ingelheim, Daiichi Sankyo, Novartis, Pfizer, Sanofi Aventis, Biotronik, Boston Scientific, Medtronic, and Abbott. The authors have no relevant financial or non-financial interests to disclose.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Grosse Meininghaus, D., Freund, R., Heimbaecher, L. et al. Incidence and clinical relevance of upper gastrointestinal pathology during preprocedural endoscopy in patients undergoing pulmonary vein isolation. Clin Res Cardiol (2022).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI:


  • Atrial fibrillation
  • Pulmonary vein isolation
  • Esophageal lesions
  • Esophagitis
  • Esophagogastroscopy
  • Endoscopic ultrasound