Atrial-oesophageal fistula following percutaneous radiofrequency catheter ablation of atrial fibrillation: the risk still persists

Abstract

Atrial-oesophageal fistula remains a serious complication following AF ablation despite the incorporation of protective measures and increased technical experience of the groups. The high morbidity and mortality despite the treatment indicates the need to develop adequate preventive strategies.

Catheter ablation of atrial fibrillation: current status, techniques, outcomes and challengesCatheter ablation of atrial fibrillation: current status, techniques, outcomes, and challenges

“…A rare but very important complication, because of the life-threatening character and the poor outcome, is atrial-oesophageal fistula caused by thermal injury of the oesophagus due to the anatomic vicinity of the oesophagus to the posterior left atrial wall. This complication occurs with a time delay of one to four weeks after the procedure in approximately 1‰ of the cases [66], although earlier manifestations are possible [6]. Several techniques are applied to prevent the development of this catastrophic complication [67].…”

“…Although some studies report that preventive premature termination of RF energy during PVI does not affect adversely the long-term outcome of the procedure [69,70], other studies report an association of segments with PV reconnections in patients undergoing redo procedures and elevated oesophageal temperature during the index procedure [71]. It is important to know that the risk of atrial-oesophageal fistula still exists and that the above-mentioned preventive actions have limitations because the measured temperature does not necessarily reflect the true maximal temperature of the oesophagus [72], and more importantly, several cases have been reported to occur despite oesophageal temperature monitoring [66].…”

Transmural unipolar electrogram change occurs within 7 s at the left atrial posterior wall during pulmonary vein isolation

“…Considerable research efforts have focused on the identification of optimal RF targets for lesion creation during pulmonary vein isolation (PVI); following the development of contact force (CF)‐sensing catheters, recommendations for the CF “working range” and force time integral (FTI, area under the force‐time curve) were derived . However, recent reports of an increased association of CF‐sensing catheter use with atrioesophageal fistula—the most feared complication following PVI due to its high mortality—suggest that these recommendations may be inappropriate and highlight the risk of conducting PVI with an imperfect understanding of when TM ablation has been achieved.…”

Mechanistic insights into heterogeneous radiofrequency ablation effects at the left atrial posterior wall during pulmonary vein isolation

“…However, delivering permanently overlapping and transmural (TM) lesions without complications is a complex undertaking; on the one hand, non-TM lesions result in late pulmonary vein (PV) electrical gaps and recurrent AF 2 , whereas excessive focal radiofrequency (RF) energy delivery risks life-threatening extra-cardiac thermal trauma. 3 Recently, RF annotation modules have been developed in an effort to provide guidance towards appropriate "per-site" RF delivery during RF PVI. These include novel systems for assessing the adequacy of "per-site" RF lesions, using weighted formulae incorporating catheter-tissue contact-force (CF), RF power and duration.…”