Clinical Manifestations, Outcomes, and Mortality Risk Factors of Atrial-Esophageal Fistula: A Systematic Review

Abstract

<b><i>Introduction:</i></b> Atrial-esophageal fistula (AEF) is a rare but life-threatening complication of catheter ablation. The clinical presentation and mortality risk factors of AEF have not been fully elucidated. The aim of this study was to systematically review the clinical characteristics and prognosis of AEF. <b><i>Methods:</i></b> PubMed was searched from inception to October 2020 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement protocol. <b><i>Results:</i></b> A total of 190 AEF patients were included. The mean age was 59.29 ± 11.67 years, 74.21% occurred in males, and 81.58% underwent radiofrequency ablation. AEF occurred within 30 days after ablation in 80.82% of patients and occurred later in patients presenting with neurological symptoms compared with other symptoms (median of onset time: 27.5 days vs. 16 days, <i>p</i> < 0.001). Clinical presentation included fever (81.58%) and neurological symptoms (80.53%). Chest computed tomography (abnormal rate of 91.24%) was the preferred diagnostic test, followed by magnetic resonance imaging of the brain (abnormal rate of 90.91%). Repeated testing improved diagnostic evaluation sensitivity. Distinctive imaging results included free air in the mediastinum (incidence rate of 81.73%) and air embolism of the brain (incidence rate of 57.53%). The overall mortality was 63.16%, with worse nonsurgical treatment outcomes compared with outcomes of surgical treatment (94.19% vs. 33.71%, <i>p</i> < 0.001). Conservative or stent intervention was an independent risk factor for mortality. Age (adjusted odds ratio, 1.063, <i>p</i> = 0.004), presentation with neurological symptoms (adjusted odds ratio, 5.706, <i>p</i> = 0.017), and presentation with gastrointestinal bleeds (adjusted odds ratio, 3.009, <i>p</i> = 0.045) were also predictors of mortality. <b><i>Conclusions:</i></b> AEF is a fatal ablation complication. AEF can be diagnosed using a combination of a clinical history of ablation, infection, or neurological symptoms and an abnormal chest CT. Our analysis supports that surgical treatment reduces the mortality rate.

Acquired atrioesophageal fistula: Need it be lethal? Sizing up the problem, diagnostic modalities, and best management

“…Our findings agree with those of the previous reviews 12,16,17 that emergency surgical repair offers the best chance of survival. In this review, we looked at the outcomes in surgical repair subgroups in an attempt to evaluate the most effective surgical techniques for this dangerous condition.…”

“…In hospitals where an MRI head is likely to be delayed, we suggest that a CT head should be performed in the meantime. Our results support those of Liu et al 17 that repeat cerebral imaging is advisable in the event of an unremarkable initial scan as a significant number of additional cases may be detected.…”

“…The most common symptoms were fever, intermittent neurological dysfunction, and chest pain; these findings support those of other reviews 12,17 . A history of these symptoms in the context of recent ablation should prompt immediate evaluation.…”

“…We agree with Chavez et al 14 and Liu et al 17 that procedures involving esophageal instrumentation, including OGD and TOE, should be avoided at all costs when there is any suspicion of an AOF to avoid the risk of catastrophic air embolism or massive UGI hemorrhage. It has been suggested that OGD using CO2 insufflation could be used for diagnosis when an initial CT is unremarkable as it presents a lower risk of clinically relevant air embolism.…”

Atrial-esophageal fistula after atrial fibrillation ablation: a case report and literature review

“…The severity of clinical symptoms mainly depends on the extent of the damage to the esophagus and left atrium. The most common symptoms are fever (81.6%), neurological abnormity (59.5%), chest discomfort (33.68%), and hematemesis (32.11%) ( 4 ).…”