Esophageal Fistula and High Mortality After Catheter Ablation for AF

Esophageal fistula after catheter ablation for atrial fibrillation (AF) is more likely to occur following use of radiofrequency energy vs cryoenergy and is associated with a very high mortality rate, according to study findings published in the European Heart Journal.

Investigators sought to assess clinical outcomes, management, and incidence of esophageal fistula following catheter ablation for treatment of atrial tachycardia (AT) or AF. The primary endpoint was esophageal fistula occurrence following catheter ablation for AT or AF treatment. Diagnosis and management of esophageal fistula and mortality were secondary endpoints.

They conducted the retrospective POTTER-AF (Prognosis Following Oesophageal Fistula Formation in Patients Undergoing Catheter Ablation for AF; ClinicalTrials.gov Identifier: NCT05273645) study at the Department of Rhythmology at the Lübeck University Heart Center, University Hospital Schleswig-Holstein, Germany. The investigators included data from 553,729 deidentified catheter ablation procedures (62.9% radiofrequency; 36.2% cryoballoon; 0.9% other modalities) worldwide between 1996 and 2022. Procedures were performed in 35 countries at 214 centers, during which 138 patients (0.025%) in 78 centers were diagnosed with esophageal fistula (0.038% radiofrequency; 0.0015% cryoballoon; P <.0001). The study had no exclusion criteria.

There were 118 patients with available periprocedural data (mean age, 62.0±11.4 years; 47% women; 8% history of esogastric pathology; 23% preprocedural proton pump inhibitor therapy). The energy source was radiofrequency in 96.6% of patients.

Median time to diagnosis following catheter ablation was 21 days (IQR, 15.0-29.5; range, 2.0-63.0). Median time to symptoms following catheter ablation was 18 days (IQR, 7.75-25.00; range, 0.00-60.00). From symptom onset to esophageal fistula diagnosis (80.2% established by chest computed tomography), median time was 3 days (IQR, 1.0-9.0; range 0.0-42.0). Fever and neurological symptoms were reported by all early diagnosed patients.

Fever was the most common initial symptom (59.3%), followed by chest pain or pain when swallowing (54.2%), and stroke or seizures (44.1%). Additional symptoms occurred in 62.3% of patients, with 1 patient reporting no symptoms. Delayed complications that presented during the clinical course included septic shock (57.9%), coma (46.7%), cerebral hemorrhages (23.4%), cardiac arrest (18.7%), gastrointestinal bleeding (16.8%), and cardiac tamponade (11.2%). There were 29% of patients who experienced additional complications, and no complications were reported by 4.7% of patients.

There were 32.8% of patients who received conservative management, 19.8% who received endoscopic treatment only, and 47.4% who received esophageal surgery. In patients who received conservative management, median time from procedure to earliest symptom onset was 20.5 days (IQR, 10.0-29.0) and median time from procedure to esophageal fistula diagnosis was 26.5 days (IQR, 19.0-32.0). In patients who received endoscopic treatment only, median time from procedure to earliest symptom onset was 10.0 days (IQR, 6.0-15.0) and median time from procedure to esophageal fistula diagnosis was 18.0 days (IQR, 10.0-25.0). In patients who received esophageal surgery, median time from procedure to earliest symptom onset was 18.0 days (IQR, 11.0-22.5) and median time from procedure to esophageal fistula diagnosis was 21.0 days (IQR, 15.0-29.0).

Mortality was high following isolated endoscopic treatment (56.5%) or esophageal surgery (51.9%), and was even higher in the conservative treatment group (89.5%; odds ratio, 7.463; 95% CI, 2.414-23.072; P <.001). Intravenous antibiotic therapy was given to all patients.

Study limitations include possible selection bias, patients that were lost to follow-up, and potential lack of generalizability.

“Esophageal fistula after catheter ablation of atrial fibrillation is rare and occurs mostly with the use of radiofrequency energy rather than cryoenergy,” the investigators wrote. “Mortality without surgical or endoscopic intervention is exceedingly high.”