Atrial‐esophageal fistula as a complication of AF ablation: A tough one to swallow

Abstract

Disclosures: None.Catheter ablation (CA) has become a cornerstone in the treatment of symptomatic atrial fibrillation (AF). In optimal candidates, CA can reduce AF burden by an average of greater than 98% in exchange for a 4% to 5% rate of major complications. 1,2 Alongside the growth of CA and other invasive treatment options for heart rhythm disorders in the past three decades, a better understanding of the types of complications that result, particularly noncardiac, "collateral" damage, has come into focus.Accordingly, great strides have been made to improve safety and reduce all types of complications in the electrophysiology (EP) laboratory. Changes in ablation technology and techniques have sought to balance the creation of durable lesions to achieve a lasting result with the risk of complications from excessive ablation. Other efforts including ultrasound-guided vascular access, routine use of intracardiac echocardiography, esophageal temperature and phrenic nerve monitoring, uninterrupted oral anticoagulation, three-dimensional mapping to reduce fluoroscopy use, and avoidance of urinary catheters are only a sample of the strategies that are now routinely performed during EP procedures. It is thanks to these advances that patients and electrophysiologists can now take for granted a near immediate recovery, same-or next-day discharge, and rare occurrence of complications even among procedures considered to have the highest levels of complexity. Yet against this backdrop, atrioesophageal fistula (AEF) remains the most dreaded complication of CA for AF, particularly as it is such a rare event and is generally delayed weeks after a seemingly successful procedure. In addition, even if the diagnosis is made quickly, there is an unacceptably high rate of morbidity and mortality from AEF.In the present issue of Journal of Cardiovascular Electrophysiology, Assis et al 3 present a state-of-the-art review of esophageal injury during CA for AF. While recounting the features, risk factors, management, and potential preventative strategies for AEF, the authors also underscore the gaps in knowledge that have thwarted the ability to eradicate this complication. Most salient, esophageal thermal injury appears to be common as a complication of CA for AF, with an incidence of 57.1% in one study. 4 However, there are no accurate predictors of progression to AEF. This inherently complicates efforts at screening when the vast majority of endoscopically detected lesions post ablation will resolve without sequelae. Higher power output (58 ± 13 vs 41 ± 9 W) and higher ablation temperature (53 ± 6 vs 49 ± 7°C) were found among the patients with AEF in one study, and an 8mm nonirrigated catheter was used in each case with AEF, 5 however these characteristics lack specificity. Cryoballoon ablation is associated with a lower incidence of AEF, particularly when performed with the second-generation cryoballoon and interrupting ablation at an esophageal temperature of 15°C.Esophageal temperature monitoring, esophageal deviation, H2-recep...

Surgery and Catheter Ablation for Atrial Fibrillation: History, Current Practice, and Future Directions

“…As a result, the target areas for catheter ablation in the left atrium were extended beyond the PV orifices themselves to include the “antrum” of left atrial myocardium surrounding the PV orifices [ 21 ]. This enlargement of the atrial target areas resulted in an improvement in the success rates for AF ablation, but an attempt to encompass even more of the posterior wall of the LA was largely abandoned because of an increase in esophageal injury that caused lethal atrioesophageal (AE) fistulas [ 22 ]. Interventional electrophysiologists eventually settled on performing PVI’s that included as much of the surrounding antral areas as possible without risking esophageal injury.…”