Longitudinal Esophageal Wall Rupture and Mediastinitis Due to Esophageal Warming Balloon Dysfunction During Left Atrial Ultralow Cryoablation for Persistent Atrial Fibrillation: A Case Report

INTRODUCTION: Atrial fibrillation (AF) is a common supraventricular tachyarrhythmia associated with an increased risk of stroke and mortality. Catheter ablation using pulmonary vein isolation is a standard treatment for patients refractory to antiarrhythmic drugs, where radiofrequency ablation and cryoablation are the two most commonly used procedures. Although generally safe, esophageal baro- and thermal injuries remain a rare but life-threatening complication due to the close anatomical relationship between the esophagus and the left atrium. Various protective strategies, such as esophageal temperature monitoring and displacement, aim to mitigate this risk, yet their efficacy and safety are still under investigation. CASE PRESENTATION: A 72-year-old male with persistent AF underwent cryoablation with an esophageal warming device to prevent esophageal thermal injury. Despite an uneventful procedure, postoperatively, the patient developed severe thoracic pain. Imaging revealed esophageal perforation with active bleeding. Conservative management, including nil per os, antibiotics, and drainage, was initially pursued. However, worsening clinical status necessitated thoracoscopic intervention. Findings included extensive hematoma and inflammation, precluding primary repair. Conservative treatment with enteral nutrition and drainage led to gradual improvement, and the patient was discharged on Day 24. Follow-up confirmed near-complete healing, with no recurrence of AF. CONCLUSION: Severe esophageal complications post-cryoablation remain rare but pose significant morbidity. In this case, overinflation of the esophageal warming device likely contributed to barotraumatic injury, worsening of esophageal fragility, leading to a major perforation with extensive mediastinitis. While protective devices aim to reduce ETI, their potential risks must be carefully considered. Optimal patient selection and refined protective strategies are crucial to enhancing procedural safety.