Co-Author(s):
Shreya Ghetiya, MD
Allen Brown, MD
Claude Elayi, MD
Jing Xu, PhD
Fabrizio Asis, MD
Harikrishna Tandri, MD
John Catanzaro, MD
UF Health Cardiology
1505 SW Archer Road Gainesville Florida 32606
Introduction | Objectives: Atrioesophageal fistula (AEF) remains a rare and often fatal complication of percutaneous catheter ablation of atrial fibrillation (AF). Ablation energies include radiofrequency (RFE) cryotherapy (CTE) and laser (LE). Although each energy modality has a different mechanism of injury, the reports and association of energy source on the risk of atrioesophageal injury and fistula formation after catheter ablation has not been explored.
Methods: We searched the Manufacturer and User Facility Device Experience database (MAUDE) for adverse events related to AF and atrial flutter ablation procedures from 08/01/2009 to 08/31/2019 was performed. All reports were manually reviewed and e vents associated with AEF formation and esophageal injury were included. Frequency of AEF reporting were compared based on energy used with a Fisher exact test.
Results: Among 1274 reported device adverse events, we identified a total of 5.7% [73/1274] to have esophageal damage (fistula formation or injury). Among these, AEF formation occurred in 4.1 % [52/1274] and 1.6 % [21/1274] were esophageal injury. Among reports with AEF, 71.2 % (37/52) occurred with radiofrequency energy (RF), 26.9% [14/52] using cryothermal (CTE) and 1.9% [1/52] with laser energy (LE). There was no statistical difference amongst energy sources for esophageal damage related death or injury (p = 0.144).
Conclusions: The MAUDE database demonstrated that AEF and esophageal has been reported in RFE, CTE and LE ablation. There was no significant difference for the reporting of esophageal fistulas after atrial fibrillation ablation amongst different energy ablation sources. LE is a newer energy modality and continued vigilance is recommended especially when using newer energy sources during ablation for AF.  Further research into the precise mechanism of AEF formation and technological advances in esophageal protection technology is warranted to avoid such a devastating major complication.