Atrioesophageal Fistula: A Rare but Dangerous Complication From Catheter Ablation

Atrioesophageal fistula is a rare complication of catheter ablation. It can be discovered on computerized topography of the chest. It is a difficulty entity to diagnose and treat and carries a mortality between 67% and 100%. Management options include surgical repair and esophageal stenting. We report here a rare case of an atrioesophageal fistula that presented with massive upper gastrointestinal bleeding and hemiparalysis.

Esophageal Protection and Temperature Monitoring Using the Circa S-Cath™ Temperature Probe during Epicardial Radiofrequency Ablation of the Pulmonary Veins and Posterior Left Atrium

Although epicardial bipolar radiofrequency ablation should diminish the risk of esophageal thermal injury in comparison to an endocardial ablation, cases of lethal atrio-esophageal fistula have been reported. To better understand this risk and to reduce the possibility of a thermal injury, we monitored the esophageal temperature with the Circa S-Cath™ temperature probe during and immediately after the ablation while implementing three procedural safety measures. Twenty patients (15 males; 63 ± 10 years) were prospectively enrolled (November 2019-February 2021). All patients underwent an epicardial ablation procedure, including an antral left and right pulmonary vein isolation with bidirectional bipolar clamping, and a roof and inferior line using unidirectional bipolar radiofrequency. Three procedural preventive mitigations were implemented: (1) transesophageal echocardiographic visualization of the atrio-esophageal interface, with probe retraction before the energy delivery; (2) lifting the ablated tissue away from the esophagus during an energy application; and (3) a 30 s cool-off and irrigation period after the energy delivery. The esophageal temperature was recorded using an insulated multisensory intraluminal esophageal temperature probe (Circa S-Cath™). Of the 20 patients enrolled, 7 patients had paroxysmal atrial fibrillation (AF), 8 persistent AF and 5 longstanding persistent AF. The average maximum luminal esophageal temperature observed was 36.2 ± 0.7 °C (34.8-38.2 °C). In our clinical experience, no abrupt increase in the luminal esophageal temperature above the baseline was observed. Since no measurements exceeded the threshold of 39 °C, no prompt interruption of energy delivery was required. Intraluminal esophageal temperature monitoring is feasible and can be helpful in confirming correct catheter position and safe energy application in bipolar epicardial left atrial ablation. Intra-procedural preventive mitigations should be implemented to reduce the risk of esophageal temperature rises.

Esophageal thermal lesions in radiofrequency ablation for atrial fibrillation: A prospective comparative study of thermal sensors

BACKGROUND

Esophageal thermal lesion (ETL) is a complication of radiofrequency ablation for atrial fibrillation (RFAF). To prospectively compare the incidence of ETL, we used two linear, five- and three-sensor esophageal thermal monitoring catheters (ETMC5 and ETMC3). We also evaluated the predictors of ETL.

METHODS

Patients receiving their first RFAF (n = 106) were randomized into two groups, ETMC5 (n = 52) and ETMC3 (n = 54). Ablation was followed by esophagogastroduodenoscopy within 3 days.

RESULTS

Esophageal thermal lesion was detected in 7/106 (6.6%) patients (ETMC5: 3/52 [5.8%] vs. ETMC3: 4/54 [7.4%]; p = 1.0). The maximum temperature and number of measurements > 39.0°C did not differ between the groups (ETMC5: 40.5°C and 5.4 vs. ETMC3: 40.6°C and 4.9; p = .83 and p = .58, respectively). In ETMC5 group, the catheter had to be moved significantly less often (0.12 vs. 0.42; p = .0014) and fluoroscopy time was significantly shorter (79.2 min vs. 101.7 min; p = .0038) compared with ECMC3 group. The total number of ablations in ETMC5 group was significantly greater (50.2 vs. 37.7; p = .030) and ablation time was significantly longer (52.1 min vs. 40.1 min; p = .0039). Only body mass index (BMI) was significantly different between patients with and without ETL (21.4 ± 2.5 vs. 24.3 ± 3.4; p = .022).

CONCLUSIONS

The incidence of ETL was comparable between ETMC5 and ETMC3 groups; however, fluoroscopy time, total ablation time, and total number of ablations differed significantly. Lower BMI may increase the risk of developing ETL.

Esophageal Findings in the Setting of a Novel Preventive Strategy to Avoid Thermal Lesions during Hybrid Thoracoscopic Radiofrequency Ablation for Atrial Fibrillation

Purpose The development of an atrio-esophageal fistula, a rare yet potentially lethal complication of ablation for atrial fibrillation, could be related to direct tissue heat transfer during and immediately after the ablation. We therefore studied the postoperative esophageal findings by esophagogastroduodenoscopy in patients that underwent a hybrid ablation procedure using a novel preventive strategy to avoid thermal lesions. Methods Thirty-four patients (28 males; 65 years ± 9 years) were retrospectively included. All underwent a hybrid ablation in our center between April 2015 and November 2019 and agreed to an esophagogastroduodenoscopy within 0–14 days (mean: 5 days) following the ablation. To reduce the incidence of thermal lesions three procedural preventive strategies were introduced: (i) videoscopic intrathoracic transesophageal echocardiographic probe visualization to understand the relationship between posterior left atrial wall and esophagus, with probe retraction before ablation; (ii) lifting the cardiac tissue away from the esophagus during energy application; and (iii) a 30-s cool-off period after energy delivery with irrigation of the device, the ablated tissue, and the surrounding tissues. Results No esophageal thermal lesions were observed. One third of patients were diagnosed with incidental esophageal findings unrelated to the ablation procedure (11; 32.4%). Conclusion Novel preventive strategies by visualization and by avoiding contact between the ablation catheter or ablated tissue and the pericardium, seems to eliminate the potential risk of esophageal thermal lesions in the setting of hybrid ablation. Since one third of patients had preexisting esophageal disease, a more comprehensive pre-operative screening could be important to reduce the risk.

Diffuse Cerebral Air Emboli After an Esophagogastroduodenoscopy One Month Post Left Atrial Ablation for Atrial Fibrillation

We present a case of a patient who presented to the emergency department with vague abdominal pain one month after undergoing a left atrial ablation procedure for atrial fibrillation. While in the emergency department, the patient started to have episodes of hematemesis. Esophagogastroduodenoscopy (EGD) was performed and the patient become hypotensive and unresponsive after. Imaging confirmed atrioesophageal fistula and widespread cerebral air emboli and diffuse ischemia. Air emboli were likely introduced through the fistula during the EGD.

Clinical presentation, diagnosis, and treatment of atrioesophageal fistula resulting from atrial fibrillation ablation

BACKGROUND

Atrioesophageal fistula (AEF) is a worrisome complication of atrial fibrillation (AF) ablation. Its clinical manifestations and time course are unpredictable and may contribute to diagnostic and treatment delays. We conducted a systematic review of all available cases of AEF, aiming at characterizing clinical presentation, time course, diagnostic pitfalls, and outcomes.

METHODS

The digital search retrieved 150 studies containing 257 cases, 238 (92.6%) of which with a confirmed diagnosis of AEF and 19 (7.4%) of pericardioesophageal fistula.

RESULTS

The median time from ablation to symptom onset was 21 days (interquartile range [IQR]: 11-28). Neurological abnormalities were documented in 75% of patients. Compared to patients seen by a specialist, those evaluated at a walk-in clinic or community hospital had a significantly greater delay between symptom onset and hospital admission (median: 2.5 day [IQR: 1-8] vs. 1 day [IQR: 1-5); p = .03). Overall, 198 patients underwent a chest scan (computed tomography [CT]: 192 patients and magnetic resonance imaging [MRI]: 6 patients), 48 (24.2%; 46 CT and 2 MRI) of whom had normal/unremarkable findings. Time from hospital admission to diagnostic confirmation was significantly longer in patients with a first normal/unremarkable chest scan (p < .001). Overall mortality rate was 59.3% and 26.0% survivors had residual neurological deficits at the time of discharge.

CONCLUSIONS

Since healthcare professionals of any specialty might be involved in treating AEF patients, awareness of the clinical manifestations, diagnostic pitfalls, and time course, as well as an early contact with the treating electrophysiologist for a coordinated interdisciplinary medical effort, are pivotal to prevent diagnostic delays and reduce mortality.

Atrioesophageal Fistula as a Complication of Radiofrequency Ablation for Atrial Fibrillation

Atrioesophageal fistula (AEF) is an important complication of radiofrequency ablation (RFA). Delayed diagnosis is associated with increased morbidity and mortality. Despite the name "atrioesophageal fistula," fistulas functionally act esophageal to atrial, which accounts for the neurologic and infectious complications. This report presents the management of a 60-year-old male patient who was admitted to the emergency department (ED) with AEF-caused gastrointestinal bleeding. The patient was operated urgently, but he had serious comorbidities and died after the operation. The aim of this case was to evaluate patients who underwent RFA, within 10 days to two months, carefully in the ED and to know the possible complications.

Protection of the esophagus during catheter ablation of atrial fibrillation

Esophageal injury still occurs with high frequency during ablation of atrial fibrillation (AF). The purpose of this study is to provide a review of methods to protect the esophagus from injury during AF ablation. Despite advances in imaging and ablation, the potential risk of esophageal injury during AF ablation remains an important concern with a high occurrence of esophageal injury (≈15%). There have been numerous studies evaluating varied techniques for esophageal protection including active cooling and displacement of the esophagus. These techniques are reviewed in this manuscript as well as the role of esophageal protection in managing patients undergoing AF ablation procedure.

Esophageal cooling for protection: an innovative tool that improves the safety of atrial fibrillation ablation

This letter to the editor concerns the article: 'Innovative tools for atrial fibrillation ablation' by Rottner et al., published in the journal on 13th of May 2020. We read the article with great interest and congratulate the authors on an impressively detailed summary of the current tools and technological advances in atrial fibrillation ablation. Improving the safety of this procedure is very important due to widespread clinical practice and the increasing demand for this procedure. We would like to share further discussion with the authors and the journal's readership on current advances in improving the safety of this procedure - esophageal cooling. The results of a large randomized trial was recently presented, the IMPACT study (NCT03819946), which showed that a simple, standardized method of esophageal cooling with the ensoETM® device can significantly reduce esophageal thermal injury by 83.4%. Esophageal protection is important as esophageal injury has a high mortality rate to those that sustain this injury although the overall incidence is low. Rottner et al. discuss a much smaller study on esophageal cooling and the limitations of this study are also discussed.

Atrio-esophageal Fistula Secondary to Atrial Fibrillation Ablation: A Case Report

BACKGROUND

An atrio-esophageal fistula is an exceedingly rare but devastating complication of atrial fibrillation (AF) ablation procedures. Delays to diagnosis and definitive treatment herald a poor prognosis, with the development of catastrophic neurological injury or death secondary to cerebral air emboli. A high level of suspicion is essential to improve recognition of this rare but devastating condition.

CASE REPORT

A 59-year-old man presented to the emergency department with an acute stroke and reduced consciousness. This presentation was preceded by an uncomplicated AF ablation 19 days prior and a subsequent emergency department attendance within a few days of his procedure, where he had presented with a history of new chest pain and reflux symptoms. Imaging revealed intra-cranial and intra-cardiac air, which was attributed to an uncontrolled atrio-esophageal fistula. Treatment options were limited by the patient's clinical instability and the patient was eventually palliated after developing catastrophic brain injury due to extensive cerebral air emboli. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Patients typically first present to the emergency department with new symptoms of either gastroesophageal reflux or chest pain, therefore, early recognition by emergency physicians is vital. Characteristic symptoms alongside a recent history of a cardiac ablation procedure should prompt additional diagnostic imaging to look for evidence of an atrio-esophageal fistula.

Use of oral gadobenate dimeglumine to visualise the oesophagus during magnetic resonance angiography in patients with atrial fibrillation prior to catheter ablation

BACKGROUND

Atrio-oesophageal fistula was first reported as a fatal complication of surgical endocardial and percutaneous endocardial radiofrequency ablation for atrial fibrillation, with an incidence after catheter ablation between 0.03% and 0.5%. Magnetic resonance angiography (MRA) was usually performed to obtain pre-procedural 3D images, used to merging into an electro-anatomical map, guiding step-by-step ablation strategy of AF. Our aim was to find an easy, safe and cost-effective way to enhance the oesophagus during MRA.

METHODS

In 105 consecutive patients, a right-left phase encoding, free breathing, 3D T1 MRA sequence was performed in the axial plane, >24 hours before catheter ablation, using an intravenous injection of gadobenate dimeglumine contrast medium. The oesophagus was enhanced using an oral gel solution of 0.7 mL gadobenate dimeglumine contrast medium mixed with approximately 40 mg thickened water gel, which was swallowed by the patients on the scanning table, immediately before the MRA sequence acquisition.

RESULTS

The visualisation of the oesophagus was obtained in 104/105 patients and images were successfully merged, as left atrium and pulmonary veins, into an electro-anatomical map, during percutaneous endocardial radiofrequency ablation. All patients tolerated the study protocol and no immediate or late complication was observed with the oral contrast agent administration. The free-breathing MRA sequence used in our protocol took 7 seconds longer than MRA breath-hold conventional sequence.

CONCLUSION

Oesophagus visualization with oral gadobenate dimeglumine is feasible for integration of oesophagus anatomy images into the electro-anatomical map during AF ablation, without undesirable side effects and without significantly increasing cost or examination time.