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

Atrioesophageal Fistula: A Rare but Dangerous Complication From Catheter Ablation

Atrioesophageal fistula is a rare complication of catheter ablation. It can be discovered on computerized topography of the chest. It is a difficulty entity to diagnose and treat and carries a mortality between 67% and 100%. Management options include surgical repair and esophageal stenting. We report here a rare case of an atrioesophageal fistula that presented with massive upper gastrointestinal bleeding and hemiparalysis.

Atrio-Esophageal Fistula: A Rare Entity Complicating a Common Procedure

A 66-year-old female with a history of radiofrequency ablation for atrial fibrillation presented with hematemesis and fever. A CT chest revealed an atrio-esophageal fistula (AEF) and a CT head showed bilateral septic emboli. Blood cultures were positive for Streptococcus sanguinis. She underwent primary repair of the atrial defect on cardiopulmonary bypass where a large atrial vegetation was retrieved, followed by a right thoracotomy with the closure of the esophageal defect the next day. She was discharged to a rehabilitation facility after 18 days of hospital stay with a 6 weeks antibiotics plan. The incidence of AEF following ablation procedures has been estimated at 0.01 to 0.04%, and the pathogenesis is linked to direct tissue and vagus nerve injury. The most common clinical findings are fever and neurologic deficits. CT chest is the best diagnostic modality. CT head might demonstrate embolic phenomena and TTE can show vegetation. Early surgical intervention, even in an unstable patient, is paramount for survival.

Esophago-gastric Complications in Radiofrequency and Cryoballoon Catheter Ablation of Atrial Fibrillation

BACKGROUND

Direct comparison studies about the incidence of esophago-gastric complications between radiofrequency (RF) and cryoballoon (CB) catheter ablation (CA) for atrial fibrillation (AF) have been scarce. We sought to elucidate the relationship between the pulmonary vein isolation (PVI) modalities and esophago-gastric complications.

METHODS

The study population consisted of 254 patients who underwent CA for AF from November 2017 to October 2018. Finally, 160 patients were enrolled and divided into the RF and CB groups. Esophageal ulcers, gastric hypomotility, and exfoliative esophagitis detected by esophago-gastro-duodenoscopy were defined as esophago-gastric complications in this study.

RESULTS

The median age was 68 years old, with 34% being females. Esophago-gastric complications were observed in 42.5% of patients who underwent CA. According to the detailed esophago-gastric complications, the RF group had a higher prevalence of esophageal ulcers than the CB group (19% vs. 0%, p <0.0001). There was no significant difference between the two groups regarding gastric hypomotility and exfoliative esophagitis (18% vs. 28%; p = 0.15, 16% vs. 21%; p = 0.42, respectively).

CONCLUSIONS

Asymptomatic esophago-gastric complications were common in catheter ablation for atrial fibrillation. The incidence of esophageal ulcers was higher in the radiofrequency group than cryoballoon group, whereas the other esophago-gastric complications did not significantly differ. This article is protected by copyright. All rights reserved.

Preventing esophageal complications from atrial fibrillation ablation: A review

Atrioesophageal fistula is a life-threatening complication of ablation treatment for atrial fibrillation. Methods to reduce the risk of esophageal injury have evolved over the last decade, and diagnosis of this complication remains difficult and therefore challenging to treat in a timely manner. Delayed diagnosis leads to treatment occurring in the context of a critically ill patient, contributing to the poor prognosis associated with this complication. The associated mortality risk can be as high as 70%. Recent important advances in preventative techniques are explored in this review.

Preventative techniques used in current clinical practice are discussed, which include high-power short-duration ablation, esophageal temperature probe monitoring, cryotherapy and laser balloon technologies, and use of proton pump inhibitors. A lack of randomized clinical evidence for the effectiveness of these practical methods are found. Alternative methods of esophageal protection has emerged in recent years, including mechanical deviation of the esophagus and esophageal temperature control (esophageal cooling). Although these are fairly recent methods, we discuss the available evidence to date. Mechanical deviation of the esophagus is due to undergo its first randomized study. Recent randomized study on esophageal cooling has shown promise of its effectiveness in preventing thermal injuries. Lastly, novel ablation technology that may be the future of esophageal protection, pulsed field ablation, is discussed.

The findings of this review suggest that more robust clinical evidence for esophageal protection methods is warranted to improve the safety of atrial fibrillation ablation.

Surgical Repair of Atrial-Esophageal Fistula Following Catheter Ablation

Left atrial-esophageal fistula (AEF) following radiofrequency ablation for atrial fibrillation is a rare and potentially lethal complication. Although surgical management is associated with improved outcomes, the optimal approach remains to be elucidated. We describe a case of AEF which was treated with a simultaneous repair of the atrium and esophagus via a right thoracotomy with an extra-pericardial off-pump approach.