A 62 yo hypertensive woman (47kg, 150cm) underwent an elective isolation of the pulmonary veins (PVI) because of paroxysmal atrial fibrillation (AF). The procedure was successfully performed in general anesthesia using a cooled-tip (8ml/min) ablation catheter (SmartTouch SF, BW). An accessory PV was found postero-medially to the right superior (RS) PV (arrow, panel A of the figure). Ablation was performed at 20W at the posterior and 25W at the anterior left atrium (LA) for 40sec, with Visitag set at 5mm spatial averaging and FTI targeting ≥400gs. Note that the ablation included the accessory RSPV (panel A, pink-red dots). Ten days after the procedure, the patient complained of AF recurrence, followed by a transfixing chest pain 48h later. A transthoracic echocardiogram showed a minor pericardial effusion. A CAT scan revealed a pneumo-mediastinum and a pneumo-pericardium suggestive of an esophageal perforation (arrows, panel B). Because of the absence of neurological symptoms, she underwent a gastroscopy that showed an esophageal perforation 34cm below the dental arch. A right exploratory thoracotomy revealed an eso-pericardial fistula complicated by a pyopericardium (green arrow, panel C), but no perforation of the posterior LA wall. The esophageal perforation (blue arrow) was sutured and the esophagus (black arrows) wrapped with a diaphragmatic patch. Postoperative evolution was favorable under antibiotics over 4 weeks. Eso-atrial fistula is one of the most lifethreatening complications following PVI. Herein, we report a rather unique case of eso-pericardial fistula without perforation of the posterior LA. As recently shown, the catheter cooling limits local tissue damages but can shift RF energy delivery to adjacent unprotected tissue. Interestingly, an accessory PV forced us to medially extend the ablation, which might have moved the RF energy closer to the esophagus. Open in new tabDownload slide