Discussion
Ablation is one of the most frequently used treatment modalities for atrial fibrillation. AEF is a rare but dangerous complication of ablation, with an estimated occurrence in less than 0.1% - 0.25% of procedures.2 The anatomical location of the esophagus posterior to the left atrium increases the likelihood of injury during the procedure. There is no clear understanding of the mechanism of esophageal injury, however direct thermal injury, acid reflux exacerbation, infection and ischemia have been described as some of the contributing factors.3 Attempts have been made to establish a relationship between the modality of ablation used and incidence of atrio-esophageal fistula. A higher association of esophageal injury was observed with percutaneous radiofrequency ablation, although it also has been reported with other energy sources, including cryoablation, high-intensity focused ultrasound, and surgical ablation.4-6 Robotic navigated-AF ablation has been documented to have higher incidence of esophageal injury when compared to manual ablation, when similar radiofrequency ablation parameters are used.7
Atrio-esophageal fistulae usually present 1 to 6 weeks after the procedure. Symptoms are nonspecific and include fever, malaise, chest discomfort, nausea, dysphagia, and odynophagia. CT and MR imaging of chest are considered gold standard diagnostic modalities since endoscopy in suspected cases can put the patient at risk of air embolus and neurological injuries. Early diagnosis can reduce morbidity and mortality since chances of recovery are higher before the esophageal perforation forms a communicating fistulous tract with the atrium.8 Once diagnosed, early surgical repair should be considered since mortality is almost 100 % without intervention.9