A worldwide survey on incidence, management, and prognosis of oesophageal fistula formation following atrial fibrillation catheter ablation: the POTTER-AF study

Abstract

Aims Oesophageal fistula represents a rare but dreadful complication of atrial fibrillation catheter ablation. Data on its incidence, management and outcome are sparse. Methods and results This international multicenter registry investigates the characteristics of oesophageal fistulae after treatment of atrial fibrillation by catheter ablation. A total of 553,729 catheter ablation procedures (radiofrequency: 62.9%, cryoballoon: 36.2%, other modalities: 0.9%) were performed at 214 centers in 35 countries. In 78 centers 138 patients (0.025%, radiofrequency: 0.038%, cryoballoon: 0.0015% (p<0.0001)) were diagnosed with an oesophageal fistula. Periprocedural data were available for 118 patients (85.5%). Following catheter ablation, the median time to symptoms and the median time to diagnosis were 18 (7.75, 25; range: 0-60) days and 21 (15, 29.5; range: 2-63) days, respectively. The median time from symptom onset to oesophageal fistula diagnosis was 3 (1, 9; range: 0-42) days. The most common initial symptom was fever (59.3%). The diagnosis was established by chest computed tomography in 80.2% of patients. Oesophageal surgery was performed in 47.4% and direct endoscopic treatment in 19.8%, and conservative treatment in 32.8% of patients. The overall mortality was 65.8%. Mortality following surgical (51.9%) or endoscopic treatment (56.5%) was significantly lower as compared to conservative management (89.5%) (odds ratio 7.463 (2.414, 23.072) p<0.001). Conclusions Oesophageal fistula after catheter ablation of atrial fibrillation is rare and occurs mostly with the use of radiofrequency energy rather than cryoenergy. Mortality without surgical or endoscopic intervention is exceedingly high.

Comparison of pulsed field ablation and cryoballoon ablation for pulmonary vein isolation

“…Furthermore, this thermal ablation technique is of potential harm for adjacent structures such as the esophagus and phrenic nerve. 6,7 Lately, pulsed field ablation (PFA) was implemented into clinical routine as a new non-thermal ablation modality to achieve PVI. 8 Very short high voltage pulsed fields induce electroporation causing an increased permeability of cell membranes consecutively resulting in death of cardiomyocytes.…”

Pulsed field ablation for atrial fibrillation – Lessons from magnetic resonance imaging

“…56 According to a multicenter, anonymized registry study, the incidence of this complication was 0.038% after RF ablation and 0.0015% after cryoballoon PVI. 57 In contrast to thermal energy sources, PFA has been demonstrated to have sensitivity towards myocardial cells and until today, no AEF after PFA has been reported. In this context, Neven et al delivered electroporation directly on porcine esophageal tissue and did not find esophageal alterations in endoscopy investigations.…”

“…The course of the esophagus exhibits variation along the posterior aspect of the left atrium. The esophagus was found to be in contact with the posterior wall of the LA for a length of 42 ± 7 mm, with a range of 30-53 mm 57 . Additionally, the thickness of the posterior left atrial wall varies with the greatest thickness being found adjacent to the coronary sinus and the thinnest region being located more superiorly.…”

“…Additionally, the thickness of the posterior left atrial wall varies with the greatest thickness being found adjacent to the coronary sinus and the thinnest region being located more superiorly 56 . According to a multicenter, anonymized registry study, the incidence of this complication was 0.038% after RF ablation and 0.0015% after cryoballoon PVI 57 . In contrast to thermal energy sources, PFA has been demonstrated to have sensitivity towards myocardial cells and until today, no AEF after PFA has been reported.…”