Is the Esophagus Spared During Pulsed Field Ablation?

Pulsed field ablation (PFA) has emerged as a new energy source for atrial fibrillation (AF) ablation, distinguished by its tissue-selective mechanism through irreversible electroporation. PFA offered theoretical advantages over conventional radiofrequency and cryoablation techniques, particularly regarding collateral damage to phrenic nerve and esophagus. However, accumulating evidence challenges this paradigm, with growing data highlighting those thermal effects are possible and may be clinically relevant during PFA procedures. No significant esophageal complications have been reported to date, but continued vigilance is warranted given the rapidly increasing number of procedures, the trend toward multiple lesions on the posterior wall and in consideration of new PFA catheters arriving in clinical practice. This article examines current evidence on esophageal warming during PFA.