Atrioesophageal fistula following atrial fibrillation ablation: How to manage this dreaded complication?

Abstract

Atrioesophageal fistula (AEF) is a rare but serious complication of radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF). Therapeutic options are surgery, esophageal stenting and conservative treatment. However, there are no guidelines regarding the treatment of AEF following RFCA. Since no article dwells on the technical considerations of this challenging surgery, we aim to present here our experience and share our surgical approach. From January 2012 to March 2020, we identified all consecutive patients treated for AEF following RFCA at our institution (Pitié-Salpêtrière Hospital, Paris, France). The diagnosis was made on a set of clinical and radiological signs. All patients benefited from a combined approach involving both digestive and cardiac surgeons. Femoro-femoral peripheral CBP was used. The surgical approach was a right posterolateral thoracotomy. Atrial repair was done on fibrillating-heart, using a left atriotomy. Then, the digestive surgeon achieved the esophagectomy. We identified 6 patients with AEF after RFCA. All of them were males and the median age was 53 [34–72] years old. They all underwent percutaneous ablation. Symptoms were neurological symptoms ( n = 6), fever ( n = 5) and chest pain ( n = 3). Diagnostic modalities were cerebral imaging ( n = 5), Chest-CT ( n = 2) and transthoracic echocardiogram ( n = 6). Atrial repair consisted in a suture of the atrium ( n = 3) or by using a pericardial patch ( n = 3). Aftermath mainly consisted in neurological disorders ( n = 4). Most of the patients ( n = 4, 66,7%) recovered a satisfying diet. With a median follow-up of 3.1 [0.1–7.7] years, only one patient died during the follow-up. Our experience shows that an aggressive surgery with a large resection of the esophagus and left atrial repair by right thoracotomy in the same time provides good results. The ability to have both skilled digestive and cardiac surgeons available at the same time and place is the key for this strategy ( Fig. 1 ).