Puzzling Challenge of Atrioesophageal Fistula
2017; Lippincott Williams & Wilkins; Volume: 10; Issue: 11 Linguagem: Inglês
10.1161/circep.117.005837
ISSN1941-3149
AutoresEugene Crystal, Mohammed Shurrab,
Tópico(s)Cardiac electrophysiology and arrhythmias
ResumoHomeCirculation: Arrhythmia and ElectrophysiologyVol. 10, No. 11Puzzling Challenge of Atrioesophageal Fistula Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBPuzzling Challenge of Atrioesophageal Fistula Eugene Crystal, MD and Mohammed Shurrab, MD, MSc Eugene CrystalEugene Crystal From the Arrhythmia Services, Schulich Heart Centre, Sunnybrook Health Sciences Centre and Division of Cardiology, Women's College Hospital, University of Toronto, Ontario, Canada (E.C., M.S.). and Mohammed ShurrabMohammed Shurrab From the Arrhythmia Services, Schulich Heart Centre, Sunnybrook Health Sciences Centre and Division of Cardiology, Women's College Hospital, University of Toronto, Ontario, Canada (E.C., M.S.). Originally published6 Nov 2017https://doi.org/10.1161/CIRCEP.117.005837Circulation: Arrhythmia and Electrophysiology. 2017;10:e005837SeeArticle by Han et alAtrial fibrillation (AF) is the most common cardiac dysrhythmia, with a lifetime risk of about 1:4 by 80 years of age.1 The current guidelines recommend catheter ablation in patients with symptomatic AF resistant to or intolerant of antiarrhythmic medications and in selected cases even before a trial of antiarrhythmic medications.2 Shortly, the indications are very likely to extend to some congestive heart failure patients too. Not surprisingly, the utilization of catheter ablation as a treatment modality for AF patients has exploded and its annual growth rate exceeded that of many other cardiovascular procedures.3 AF ablation currently accounts for about one third of the caseload in electrophysiology laboratories in the Western world.4 Yet, the risks involved with AF ablation remain substantial. The risk of major complications is reported at 4.5%,5 whereas fatal or potentially fatal complications are occurring in 1 of 1000 patients.6The reported risk of atrioesophageal fistula (AEF) varies between different cohorts at around 0.1% and 0.2%,7,8 with a devastating subsequent mortality rate reported earlier at above 80%.9 In a recent Canadian survey accounting for 7016 AF ablations, the rate of proven AEF was 0.07% among Canadian centers.10 Likely, the rate of AEF reported in the literature does not reflect the magnitude of this serious complication in current practice given the under/miss diagnosis and the death cases of unknown cause that could be attributable to AEF. It is also because of the fact that it is a delayed complication (typically occurring weeks after the intervention), which also contributes to underreporting. One recent study reported a concerning rate of endoscopically detected asymptomatic esophageal lesions at 18% using current standard AF ablation technologies. The incidence of esophageal perforation after AF ablation was 0.6% and 0.2% for fatal outcome esophageal perforation, with 1 of 10 postablation esophageal ulcers progressed to perforation.11We read the study by Han et al12 with a great interest especially with the current heterogeneous data on AEF. Han et al12 identified 120 cases of AEF in the current literature. All cases were diagnosed within the first 2 months of AF ablation using different modalities. Fever (73%) and neurological (72%) symptoms were the most common presentation. Computed tomography (with contrast) of the chest has led to appropriate diagnosis in most of the cases. Importantly, the overall mortality was 55%, with significantly reduced mortality in patients undergoing surgical repair (33%) compared with endoscopic treatment (65%) and conservative management (97%).The study is comprehensive and is very much alarming. The clinical presentation and onset of symptoms presented by Han et al12 are consistent with real practice scenarios and encourage further attention to such symptoms with more intensive testing, especially computed tomography (with contrast) that seems to be the gold standard diagnostic tool. The mortality rate of 33% with surgical intervention is still concerning but very encouraging in comparison to earlier reports. The possible explanations are inclusiveness of more recent cases, which are better diagnosed and treated more effectively. Early surgical intervention seems to be the best management option, offering the highest survival benefit for patients with AEF.13,14There was a wide range of total ablation time, maximum temperature setting, maximum applied power reported, and variable ablation modalities used among the included cases. This is disturbing as we still cannot draw conclusions and predict the effect of the individual parameters/modalities in the development of AEF. Also, this supports the uncertainty and complexity behind the pathophysiology of the AEF. The quick approval and clinical introduction of the tools we use for AF ablation (various irrigation mechanisms, various mechanisms of lesions tagging by 3-dimensional systems, tissue contact monitoring and controlling measures, etc.) may render proper evaluation targeting rare complication rates impossible.Of particular note, in the 92 cases undergoing percutaneous radiofrequency ablation, esophageal protection methods were reported only in 31 cases including esophageal temperature monitoring and prophylactic antacid use and 7 cases reported measures to assess esophageal position. This highlights the controversial role of esophageal temperature monitoring in preventing AEF. Nevertheless, prior work has suggested that esophageal monitoring may be associated with a reduction in esophageal injury compared with power limitation alone.15 Precautionary ablation with premature termination of radiofrequency delivery using esophageal temperature monitoring does not compromise ablation efficacy.16 Indeed, limiting the radiofrequency energy delivery while ablating the posterior wall remains critical. Other preventive measures such as assessment of esophageal position by preprocedural computed tomography or magnetic resonance imaging, mechanical deflection of the esophagus moving it away from the catheter tip, esophageal cooling using a cooled water-irrigated intraesophageal balloon, or tagging of the esophagus using a 3-dimensional mapping system or intracardiac ultrasound could help in preventing AEF.17 Further assessment should be done to define the role of such measures in preventing AEF. Although data on the use of general anesthesia are limited in this report, it is clearly an important contributor in the development of AEF by suppressing esophageal motility and saliva swallowing as a major mechanism of esophageal protection. Conscious sedation could be a reasonable approach during AF ablation.In conclusion, Han et al12 provide an important data in diagnosing and treating AEF. Yet, concrete conclusions on best preventive practices are hard to make given the biases and covariates related to the included studies. Each of the individual ablation parameters and modalities should ideally be studied while controlling for other confounders to definitely assess their role. Given the high mortality rate and poor outcome even with early surgical intervention, the future efforts should be focusing on preventive measures.Further attention should be given to assess new modalities such as remote magnetic navigation, cryoballoon ablation, and contact force and explore their potential effect in the development of AEF.Remote magnetic navigation is widely adopted in AF ablation, with ≈100 000 ablations performed (majority are likely AF), no cases of AEF were formally reported at time of this report. In our world survey including 3637 procedures using remote magnetic navigation, there were no cases of AEF, likely related the flexibility of the catheter with less traumatic effect along with stability and superior catheter–tissue contact with less tissue deformation and better catheter tip cooling.18 Sadly, we are now aware of 1 proven AEF case after AF ablation using remote magnetic navigation (our personal communication). Thus, the estimate incidence of AEF in this modality may be as low as <1:50 000.AEF associated with cryoballoon ablation is also very rare with an estimated incidence of <1 in 10 000.19A recent report showed that AEF formation accounted for much a greater proportion of reported adverse events with contact force–sensing catheters compared with non–contact force-sensing catheters.13 These recent data should trigger further studies focusing on the role of power, energy, contact, and force in defining the underlying mechanism of AEF.Despite all the limitations of the data presented by Han et al,12 we think that (1) the clinical presentation findings detailed in their study should be taken into consideration when promoting early diagnostic tools for AEF (typically delayed postablation fever/sepsis with or without neurological and gastrointestinal symptoms), (2) when suspected, there is a strong case for early computed tomography (with contrast) as a leading diagnostic approach, and (3) Surgical intervention is likely the best treatment modality for AEF. We owe to our patients much better efforts in researching mechanisms and preventive measures for AEF, ultimately the most fatal but also the most unaddressed complication of the most frequent procedure we do.DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Circ Arrhythm Electrophysiol is available at http://circep.ahajournals.org.Correspondence to: Eugene Crystal, MD, Arrhythmia Services, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Suite D-377, Toronto, ON M4N 3M5, Canada. E-mail [email protected]References1. Lloyd-Jones DM, Wang TJ, Leip EP, Larson MG, Levy D, Vasan RS, D'Agostino RB, Massaro JM, Beiser A, Wolf PA, Benjamin EJ. Lifetime risk for development of atrial fibrillation: the Framingham Heart Study.Circulation. 2004; 110:1042–1046. doi: 10.1161/01.CIR.0000140263.20897.42.LinkGoogle Scholar2. 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Atrioesophageal fistula formation with cryoballoon ablation is most commonly related to the left inferior pulmonary vein.Heart Rhythm. 2017; 14:184–189. doi: 10.1016/j.hrthm.2016.10.018.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Avari H, Berkmortel C and Savory E (2020) An Insight to the Role of Thermal Effects on the Onset of Atrioesophageal Fistula: A Computer Model of Open-Irrigated Radiofrequency Ablation, Cardiovascular Engineering and Technology, 10.1007/s13239-020-00465-z, 11:4, (481-493), Online publication date: 1-Aug-2020. November 2017Vol 10, Issue 11 Advertisement Article InformationMetrics © 2017 American Heart Association, Inc.https://doi.org/10.1161/CIRCEP.117.005837PMID: 29109076 Originally publishedNovember 6, 2017 Keywordsatrioesophageal fistulafatal outcomeatrial fibrillationcatheter ablationincidenceEditorialsPDF download Advertisement SubjectsAtrial FibrillationCatheter Ablation and Implantable Cardioverter-Defibrillator
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