Late Gadolinium Enhancement Magnetic Resonance Imaging Evaluation of Post–Atrial Fibrillation Ablation Esophageal Thermal Injury Across the Spectrum of Severity

BACKGROUND: Esophageal thermal injury (ETI) is a byproduct of atrial fibrillation (AF) ablation using thermal sources. The most severe form of ETI is represented by atrioesophageal fistula, which has a high mortality rate. Late gadolinium enhancement (LGE) magnetic resonance imaging (MRI) allows identification of ETI. Hence, we sought to evaluate the utility of LGE‐MRI as a method to identify ETI across the entire spectrum of severity. METHODS AND RESULTS: All AF radiofrequency ablations performed at the University of Utah between January 2009 and December 2017 were reviewed. Patients with LGE‐MRI within 24 hours following AF ablation as well as patients who had esophagogastroduodenoscopy in addition to LGE‐MRI were identified. An additional patient with atrioesophageal fistula who had AF ablation at a different institution and had MRI and esophagogastroduodenoscopy at the University of Utah was identified. A total of 1269 AF radiofrequency ablations were identified. ETI severity was classified on the basis of esophageal LGE pattern (none, 60.9%; mild, 27.5%; moderate, 9.9%; severe, 1.7%). ETI resolved in most patients who underwent repeat LGE‐MRI at 3 months. All patients with esophagogastroduodenoscopy‐confirmed ETI had moderate‐to‐severe LGE 24 hours after ablation MRI. Moderate‐to‐severe LGE had 100% sensitivity and 58.1% specificity in detecting ETI, and a negative predictive value of 100%. Atrioesophageal fistula was visualized by both computed tomography and LGE‐MRI in one patient. CONCLUSIONS: LGE‐MRI is useful in detecting and characterizing ETI across the entire severity spectrum. LGE‐MRI exhibits an extremely high sensitivity and negative predictive value in screening for ETI after AF ablation.