Management of Atrio-Esophageal Fistula Following Left Atrial Ablation

Abstract

Currently, no guidelines have been established for the treatment of atrio-esophageal fistula (AEF) secondary to left atrial ablation therapy. After comprehensive literature review, we aim to make suggestions on the management of this complex complication and also present a case series. We performed a review of the existing literature on AEF in the setting of atrial ablation. Using keywords atrial fibrillation, atrial ablation, fistula formation, atrio-esophageal fistula, complications, interventions, and prognosis, a search was made using the medical databases PUBMED and MEDLINE for reports in English from 2000 to April 2015. A statistical analysis was performed to compare the three different intervention arms: medical management, stent placement and surgical intervention. The results of our systematic review confirm the high mortality rate associated with AEF following left atrial ablation and the necessity to diagnose atrio-esophageal injury in a timely manner. The mortality rates of this complication are 96% with medical management alone, 100% with stent placement, and 33 % with surgical intervention. Atrio-esophageal injury and subsequent AEF is an infrequent but potentially fatal complication of atrial ablation. Early, prompt, and definitive surgical intervention is the treatment of choice.

Lessons of the month 1: Fatal oesophago-pericardial fistula with cerebral air embolism after elective atrial fibrillation ablation

“…Medical management alone and stent placement have been proved to be unsuccessful with nearly 100% mortality. 4 In our case, haemodynamic instability and the devastating neurological prognosis precluded the option for definitive intervention.…”

Katheterablation von Vorhofflimmern

“…Einzige kurative Option ist die operative Sanierung, wobei auch diese mit hoher Letalität vergesellschaftet ist [32]. In palliativer Intention und zur Akuttherapie bei inoperablen Patienten kommt die Implantation eines gecoverten Stents infrage [32]. Therapeutisch stehen interventionell die Ballondilatation und die Stentimplantation zur Verfügung.…”

Esophageal cooling for protection during left atrial ablation: a systematic review and meta-analysis

“…Thermal damage to the esophagus is a risk from radiofrequency (RF) ablation or cryoablation of the left atrium for the treatment of atrial fibrillation (AF) [1][2][3]. The most extreme type of thermal injury is an atrioesophageal fistula (AEF), with a mortality rate of 80% or more [4][5][6][7][8]. Various strategies for protecting the esophagus during RF ablation or reducing the severity of injury have been developed, including power reduction, avoidance of greater contact force, temperature monitoring, esophageal deviation, and esophageal cooling, with varying degrees of success [9][10][11].…”