Background:
Esophageal injury is a rare but potentially fatal complication of atrial fibrillation (AF) catheter ablation. Data on lesion-specific outcomes are limited.
Objective:
To evaluate presentation, diagnosis, management, and prognosis of treatment-requiring esophageal lesions after AF ablation.
Methods:
A retrospective analysis was performed on 36 patients with treatment-requiring esophageal complications after AF ablation. Recorded variables included ablation technique, presenting symptoms, diagnostic modality, lesion type, therapy, and clinical outcome. Lesions were categorized into deep thermal lesions without esophageal perforation, atrio-esophageal fistulas, esophago-mediastinal fistulas, and esophago-pericardial fistulas.
Results:
Radiofrequency ablation was performed in 31 patients (86.1%), IRAAF in 3 (8.3%), and cryoablation in 2 (5.6%). Diagnosis was established by CT in 9 cases (25.0%), by esophagoscopy in 24 (66.7%), and by both in the remainder. Common symptoms included recurrent AF (13, 36.1%), fever (9, 25.0%), odynophagia (9, 25.0%), stroke (9, 25.0%), chest pain (8, 22.2%), pericardial tamponade (7, 19.4%), and gastrointestinal bleeding (3, 8.3%).
1) Deep thermal lesions without esophageal perforation (n = 7):
4 treated with clips (all healed), 3 with stents; 1 stent-treated patient died, likely due to progression to an atrio-esophageal fistula.
2) Atrio-esophageal fistulas (n = 10):
8 surgically treated, 2 with stents. One surgical and one stent-treated patient died. Two patients developed recurrent fistulas after surgery and were treated with IRAAF ablation.
3) Esophago-mediastinal fistulas (n = 12):
10 treated with clips, 1 with VAC, and 1 with a stent. The stent-treated patient later required surgery and died likely due to progression to an atrio-esophageal fistula; the remaining patients healed.
4) Esophago-pericardial fistulas (n = 7):
1 treated surgically, 4 with stents, 1 with stent + clip, and 1 with clipping alone; all patients healed.
Overall mortality was 11.1% (4/36) and occurred exclusively in patients with atrio-esophageal fistulas, either as the primary lesion or due to progression from a thermal lesion.
Conclusion:
Treatment-requiring esophageal lesions after AF ablation show markedly different prognoses depending on lesion type. Deep thermal lesions without esophageal perforation and esophago-pericardial fistulas generally healed after endoscopic or interventional therapy, whereas esophago-mediastinal fistulas carried intermediate risk. Atrio-esophageal fistulas were associated with the highest mortality and recurrence. Early recognition and lesion-specific management are essential to improve outcomes.
