Prevention and Treatment of Atrioesophageal Fistula Related to Catheter Ablation for Atrial Fibrillation

Abstract

Atrioesophageal fistula (AEF) is an uncommon but devastating complication of catheter ablation for atrial fibrillation. Even with appropriate recognition and treatment, mortality is greater than 30% in most studies. If AEF is suspected, it is essential to avoid endoscopy and to order immediate cross-sectional imaging. If the diagnosis is confirmed, a thoracic surgeon should be promptly notified and must assess the patient urgently. The prognosis for AEF is poor even if it is appropriately recognized and addressed, so prevention must be a high priority. Prevention of AEF should involve the use of low-risk and cost-effective measures during ablation, which may increase safety, efficacy, or both. These strategies may include conscious sedation (as opposed to general anesthesia), low-power ablation, low-flow irrigation, short-duration lesions, esophageal temperature measurement, esophageal deviation, and pharmacologic prophylaxis with proton pump inhibitors or histamine H 2 receptor blockers. Multiple new technologies are now becoming available, which may further reduce esophageal injury. Proceduralists should be aware of the available techniques and equipment that may help to reduce the risk of AEF, while simultaneously considering the possibility of unintended consequences.

Esophagogastric complications in radiofrequency and cryoballoon catheter ablation of atrial fibrillation

“…The EGD was performed after the CA, and a part of the population was reported in our previous paper. 7 The following patients were excluded: (1) patients who had a previous history of CA, (2) those who did not undergo EGD after CA, or (3) those who had performed additional procedures with the PVI. Finally, 160 patients were enrolled in this study (Figure 1).…”

“…The incidence of complications has decreased with the improvement in ablation procedures and devices; however, it still occurs with a certain probability. Symptomatic esophageal or gastric collateral damage, including atrioesophageal fistulae, esophagitis, esophageal ulcers, and gastric hypomotility, are rare but severe complications during the procedures 1–6 . In general, radiofrequency (RF) and cryoballoon (CB) CA are the most popular devices for pulmonary vein isolation (PVI).…”

“…Symptomatic esophageal or gastric collateral damage, including atrioesophageal fistulae, esophagitis, esophageal ulcers, and gastric hypomotility, are rare but severe complications during the procedures. [1][2][3][4][5][6] In general, radiofrequency (RF) and cryoballoon (CB) CA are the most popular devices for pulmonary vein isolation (PVI). Although the complication rate of each procedure has been separately reported, studies that directly made a comparison between the procedures have been scarce.…”

Preventing esophageal complications from atrial fibrillation ablation: A review

“…It is probably a combination of these factors that can cause necrosis in this location to extend and destroy the esophageal wall, permitting the formation of ulcers, perforations or fistulae into the pericardial space or the left atrial cavity. [12][13][14][15] (Figure 2).…”

“…In the esophagus it can be lethal because the esophagus differs in being exposed to bacterial action and to regurgitated stomach contents that include hydrochloric acid and sometimes bile and digestive enzymes. It is probably a combination of these factors that can cause necrosis in this location to extend and destroy the esophageal wall, permitting the formation of ulcers, perforations, or fistulae into the pericardial space or the left atrial cavity 12 , 13 , 14 , 15 ( Figure 2 ).

Figure 1 Postmortem photograph of the dissected left atrium: the posterior aspect is viewed from the epicardial perspective.

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