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Esophageal Fistula Following AF Catheter Ablation
Quick Takes
- In this registry of over half a million atrial fibrillation ablations, esophageal fistula had incidence of 0.025%, and occurred mostly with radiofrequency energy (0.038%) rather than cryoenergy (0.0015%, p < 0.0001).
- In this registry report on complications of atrial fibrillation ablation, mortality was high despite surgical (52%) or endoscopic treatment (57%), but it was significantly higher in patients managed conservatively (90%).
Study Questions:
What is the incidence, management, and outcome of esophageal fistula following catheter ablation of atrial fibrillation?
Methods:
The POTTER-AF study investigators reported complications of esophageal fistula in a multicenter registry of catheter atrial fibrillation. There were 214 participating centers in 35 countries.
Results:
A total of 553,729 catheter ablation procedures (radiofrequency: 63%, cryoballoon: 36%) were performed. Esophageal fistula was reported in 138 patients (0.025%, radiofrequency: 0.038%, cryoballoon: 0.0015% [p < 0.0001]). Periprocedural data were available for 118 patients (86%). Following catheter ablation, the median time to symptoms and the median time to diagnosis were 18 days and 21 days, respectively. The most common initial symptom was fever (59%). The diagnosis was established by chest computed tomography in 80% of patients. Esophageal surgery was performed in 47% of patients, direct endoscopic treatment was done in 20%, and conservative treatment in 33% of patients. The overall mortality was 66%. Mortality following surgical (52%) or endoscopic treatment (57%) was significantly lower as compared to conservative management (90%) (odds ratio, 7.5; p < 0.001).
Conclusions:
The authors conclude that esophageal fistula after catheter ablation of atrial fibrillation is rare and occurs mostly with the use of radiofrequency energy rather than cryoenergy. Mortality is very high despite surgery or endoscopic treatment, and it is even higher with conservative management.
Perspective:
Esophageal fistula connecting the left atrium and the esophagus is the most feared complication of catheter ablation for atrial fibrillation. Ablation delivered to the posterior left atrial wall may lead to thermal damage of the esophagus. This has been recognized with both radiofrequency and cryoablation, and operators routinely employ strategies to reduce this risk as much as possible. It is reassuring that the complication is so exceedingly rare. Nascent ablation technologies such as pulsed field ablation utilizing nonthermal energy source is expected to enhance the safety of the procedure further. High index of suspicion is essential in the timely diagnosis of this complication, and surgery reduces the exceedingly high mortality from about 90% to about 50%.
Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Interventions and Imaging, Computed Tomography, Nuclear Imaging
Keywords: Ablation Techniques, Arrhythmias, Cardiac, Atrial Fibrillation, Cardiac Surgical Procedures, Catheter Ablation, Conservative Treatment, Cryosurgery, Endoscopy, Esophageal Fistula, Heart Atria, Radiofrequency Ablation, Tomography, X-Ray Computed
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