Background-Left atrioesophageal fistula is a devastating complication of atrial fibrillation ablation. There is no standard approach for avoiding this complication, which is caused by thermal injury during ablation. The objectives of this study were to evaluate the course of the esophagus and the temperature within the esophagus during pulmonary vein antrum isolation (PVAI) and correlate these data with esophagus tissue damage. Methods and Results-Eight-one patients presenting for PVAI underwent esophagus evaluation that included temperature probe placement. Esophagus course was obtained with computed tomography, 3D imaging (NAVX), or intracardiac echocardiography. For each lesion, the power, catheter and esophagus temperature, location, and presence of microbubbles were recorded. Lesion location and esophagus course were defined with 6 predetermined left atrial anatomic segments. Endoscopy evaluated tissue changes during and after PVAI. Of 81 patients, the esophagus coursed near the right pulmonary veins in 23 (28.4%), left pulmonary veins in 31 (38.3%), and mid-posterior wall in 27 (33%

IntroductionAs catheter-based ablative therapies of cardiac arrhythmias become standard of care, establishing and refining the tools used for these procedures has become critical. With a wide variety of energy sources now available for use in arrhythmia ablation, understanding advantages, disadvantages, and specific uses of each modality can help physicians choose the best modality to achieve a successful result. This article reviews many of the energy sources currently available and discusses each modality's potential advantages, disadvantages, and uses in a wide variety of electrophysiologic procedures.

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