Fatal course of esophageal stenting of an atrioesophageal fistula after atrial fibrillation ablation.

The development of an atrioesophageal fistula after catheter ablation of atrial fibrillation (AF) is fortunately a rare but almost always lethal complication, representing the second most frequent cause of death after pulmonary vein isolation (PVI) following cardiac tamponade (prevalence 0.04%, mortality 71%). 1 Cappato R. Calkins H. Chen S.-A. et al. Updated worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circ Arrhythm Electrophysiol. 2010; 3: 32-38 Crossref PubMed Scopus (1530) Google Scholar Risk factors for this rare event are not yet established. The prevalence of esophageal and mediastinal injuries after PVI varies considerably in different studies and is possibly associated with the formation of an atrioesophageal fistula. 2 Zellerhoff S. Ullerich H. Lenze F. et al. Damage to the esophagus after atrial fibrillation ablation: just the tip of the iceberg? High prevalence of mediastinal changes diagnosed by endosonography. Circ Arrhythm Electrophysiol. 2010; 3: 155-159 Crossref PubMed Scopus (84) Google Scholar , 3 Yokoyama K. Nakagawa H. Seres K.A. et al. Canine model of esophageal injury and atrial-esophageal fistula after applications of forward-firing high-intensity focused ultrasound and side-firing unfocused ultrasound in the left atrium and inside the pulmonary vein. Circ Arrhythm Electrophysiol. 2009; 2: 41-49 Crossref PubMed Scopus (59) Google Scholar , 4 Martinek M. Meyer C. Hassanein S. et al. Identification of a high-risk population for esophageal injury during radiofrequency catheter ablation of atrial fibrillation: procedural and anatomical considerations. Heart Rhythm. 2010; 7: 1224-1230 Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar Schmidt et al 5 Schmidt M. Nölker G. Marschang H. et al. Incidence of oesophageal wall injury post-pulmonary vein antrum isolation for treatment of patients with atrial fibrillation. Europace. 2008; 10: 205-209 Crossref PubMed Scopus (131) Google Scholar reported a very high prevalence of 47% esophageal injury diagnosed by conventional endoscopy, whereas other studies reported lower rates of esophageal changes. We were not able to show mucosal esophageal injury in a series of 29 patients, yet structural changes of the mediastinum diagnosed by endosonography occurred in 27% of the patients. 2 Zellerhoff S. Ullerich H. Lenze F. et al. Damage to the esophagus after atrial fibrillation ablation: just the tip of the iceberg? High prevalence of mediastinal changes diagnosed by endosonography. Circ Arrhythm Electrophysiol. 2010; 3: 155-159 Crossref PubMed Scopus (84) Google Scholar Avoidance strategies in daily practice are diverse: monitoring the course of the esophagus using various imaging modalities, measuring the luminal esophageal temperature, reducing the power while ablating at the posterior wall of the left atrium, and performing the ablation procedure under conscious sedation rather than general anesthesia to observe pain as a surrogate for esophageal injury. 6 Mönnig G. Wessling J. Juergens K. et al. Further evidence of a close anatomical relation between the oesophagus and pulmonary veins. Europace. 2005; 7: 540-545 Crossref PubMed Scopus (15) Google Scholar , 7 Piorkowski C. Hindricks G. Schreiber D. et al. Electroanatomic reconstruction of the left atrium, pulmonary veins, and esophagus compared with the “true anatomy” on multislice computed tomography in patients undergoing catheter ablation of atrial fibrillation. Heart Rhythm. 2006; 3: 317-327 Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar , 8 Aryana A. Heist E.K. d'Avila A. et al. Pain and anatomical locations of radiofrequency ablation as predictors of esophageal temperature rise during pulmonary vein isolation. J Cardiovasc Electrophysiol. 2008; 19: 32-38 Crossref PubMed Google Scholar Apart from this procedural management, the optimal follow-up after ablation to detect esophageal and mediastinal injuries is also unknown and may include extensive endoscopic evaluation of the esophagus. 2 Zellerhoff S. Ullerich H. Lenze F. et al. Damage to the esophagus after atrial fibrillation ablation: just the tip of the iceberg? High prevalence of mediastinal changes diagnosed by endosonography. Circ Arrhythm Electrophysiol. 2010; 3: 155-159 Crossref PubMed Scopus (84) Google Scholar Despite these precautions, atrioesophageal fistulas still pose a problem, especially since establishing the correct diagnosis may be difficult. Additionally, initiation of therapy is often delayed because of late development of the fistula after ablation. Typical symptoms in the case of a fistula are fever, sepsis, and fluctuating neurological symptoms. 9 Stöllberger C. Pulgram T. Finsterer J. Neurological consequences of atrioesophageal fistula after radiofrequency ablation in atrial fibrillation. Arch Neurol. 2009; 66: 884-887 Crossref PubMed Scopus (40) Google Scholar Treatment options include surgery and interventional stenting of the esophagus. 10 Bunch T.J. Nelson J. Foley T. et al. Temporary esophageal stenting allows healing of esophageal perforations following atrial fibrillation ablation procedures. J Cardiovasc Electrophysiol. 2006; 17: 435-439 Crossref PubMed Scopus (112) Google Scholar , 11 Dagres N. Kottkamp H. Piorkowski C. et al. Rapid detection and successful treatment of esophageal perforation after radiofrequency ablation of atrial fibrillation: lessons from five cases. J Cardiovasc Electrophysiol. 2006; 17: 1213-1215 Crossref PubMed Scopus (91) Google Scholar Nevertheless, morbidity as well as mortality remain high.