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