First Author
Key words: ablation, atrial fibrillation, esophageal fistula
Catheter ablation for atrial fibrillation (AF) is now a cornerstone of rhythm control therapy. However, as its safety profile improves and its use expands worldwide, attention has increasingly focused on rare yet catastrophic adverse events. The case presented by Jiang et al1 in this issue of JACC: Case Reports describes a pericardial-esophageal fistula (PEF) after combined ethanol infusion into the vein of Marshall (VOM) and extensive left atrial (LA) radiofrequency ablation (RFA). PEF is a devastating yet survivable complication underscoring how multiple energy sources and ablation strategies can converge on a fragile anatomic interface.
In the case, a 69-year-old man with drug-resistant AF and ventricular pre-excitation underwent ethanol infusion into the VOM, followed by extensive LA RFA (pulmonary vein isolation, posterior wall, and mitral isthmus lesions). In the same session, a left posterolateral accessory pathway was also ablated. The procedure was uneventful, and the patient was discharged on postoperative day 3 with gastroprotective therapy. Nine days after the procedure, the patient presented with high-grade fever, chest tightness, and signs of sepsis with features of heart failure. Computed tomography showed pneumopericardium and loss of tissue planes between the LA and esophagus, consistent with PEF. Pericardiocentesis was performed, and then the patient underwent successful surgery, with the intraoperative finding of a 0.5 × 0.5 cm midesophageal perforation communicating with the pericardium. The defect was closed with full-thickness sutures and an omental flap under extracorporeal circulatory support. Delayed esophageal stenting resulted in full recovery, with stent removal at 6 months.
Preparing for a Once-in-a-Lifetime Complication
Esophageal fistula (EF) is among the most feared complications of AF ablation. The POTTER-AF registry2 reported an incidence of 0.025% and a mortality exceeding 65%, with RFA associated with significantly higher EF incidence compared with other ablation modalities. Atrioesophageal fistula was by far the most common manifestation (95.8%), whereas PEF occurred much less frequently (3.4%).2 The overall rarity of EF precludes prospective trials, so clinicians rely on expert consensus and case-based data.
The posterior LA wall and esophagus are separated by only 2 to 5 mm with high variability, and a shorter distance between the LA posterior wall and the esophagus has been linked to an increased risk of esophageal thermal injury.3,4 This, combined with the fact that transmural lesions can easily develop through the thin posterior wall with RFA, explains the underlying basis of EF formation in the setting of AF RFA.5 To date, no case of EF has been reported after combined ethanol infusion into the VOM and LA RFA, and the most recent meta-analysis of randomized controlled trials comparing combined VOM + RFA with RFA alone (including 1,045 patients) found no difference in the rate of major complications and did not report any case of EF.6 Nevertheless, it is plausible that the combined approach may increase the risk of EF formation, particularly considering that in a cadaveric study by Delgove et al,7 in approximately 20% of specimens, the VOM also received collateral branches from the posterior wall of the left atrium, implying that chemical ablation of this region could occur during VOM ethanol infusion, potentially potentiating the effects of posterior wall RF energy. Awareness of potential complications arising from the combination of different ablation modalities is particularly important in the current era of catheters capable of delivering multiple energy sources within a single platform (eg, RFA and pulsed-field ablation),8 where overlapping lesions at the same site may markedly increase lesion volume and amplify the extent of tissue injury.9
Once suspected, prompt diagnosis and surgical repair are essential; conservative management is almost uniformly fatal.2 Nevertheless, even with timely and appropriate surgical intervention, management remains extremely challenging, because preoperative imaging findings may not always reflect the true intraoperative anatomy. Therefore, the surgical team should be prepared for the potential presence of an atrioesophageal fistula even when imaging suggests a PEF, and extracorporeal circulatory support should be readily available.10
Funding Support and Author Disclosures
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Footnotes
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
References
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