Abstract
Atrioesophageal fistula (AEF) is an uncommon but devastating complication of catheter ablation for atrial fibrillation. Even with appropriate recognition and treatment, mortality is greater than 30% in most studies. If AEF is suspected, it is essential to avoid endoscopy and to order immediate cross-sectional imaging. If the diagnosis is confirmed, a thoracic surgeon should be promptly notified and must assess the patient urgently. The prognosis for AEF is poor even if it is appropriately recognized and addressed, so prevention must be a high priority. Prevention of AEF should involve the use of low-risk and cost-effective measures during ablation, which may increase safety, efficacy, or both. These strategies may include conscious sedation (as opposed to general anesthesia), low-power ablation, low-flow irrigation, short-duration lesions, esophageal temperature measurement, esophageal deviation, and pharmacologic prophylaxis with proton pump inhibitors or histamine H2 receptor blockers. Multiple new technologies are now becoming available, which may further reduce esophageal injury. Proceduralists should be aware of the available techniques and equipment that may help to reduce the risk of AEF, while simultaneously considering the possibility of unintended consequences.
Highlights
Atrial fibrillation (AF) is the most common clinically relevant arrhythmia in the world, with more than five million new cases presenting per year.[1]
Leshem et al demonstrated in a swine model that ablation with the QDOT-Micro catheter (BiosenseWebster, Diamond Bar, CA, USA) at 90 W for four seconds resulted in contiguous transmural lines, as compared with 25 W for 20 seconds, which resulted in gaps and nontransmurality
Much of the discussion on atrioesophageal fistula (AEF) prevention has centered around radiofrequency ablation, AEF has been observed after virtually all methods of AF ablation, including surgical ablation, high-intensity ultrasound ablation, and balloon cryoablation, in which AEF most often develops adjacent to the left inferior pulmonary vein (PV).[2,5]
Summary
Atrial fibrillation (AF) is the most common clinically relevant arrhythmia in the world, with more than five million new cases presenting per year.[1]. These complications consist of vascular events such as hemorrhage, myocardial infarction, stroke, cardiac tamponade, and atrioesophageal fistula (AEF).[4] The last is the least common, occurring in less than 0.1% of cases, but it can have delayed and devastating consequences.[1,3,5] AEF can be rapidly fatal, even with appropriate treatment.[1] It is the second most common cause of mortality related to AF ablation and is linked to 16% of postprocedural deaths.[2] Because of this, the risk of AEF informs and constrains the method of ablation on the posterior wall of the left atrium (LA) in an attempt to prevent this complication. We will discuss appropriate safety measures as well as new and experimental techniques and equipment aimed at preventing. We will discuss optimal management of AEF and associated conditions
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