Esophageal fistula (EF) is a uncommon however severe complication of catheter ablation for atrial fibrillation (AF), with excessive mortality. Partly due to its rarity, numbers on its incidence, administration, and outcomes have been arduous to come back by.
The very giant Prognosis Following Oesophageal Fistula Formation in Sufferers Present process Catheter Ablation for AF (POTTER AF) examine has offered a few of these knowledge, documenting a 65.8% mortality price for circumstances, in addition to important delays in prognosis. The strategy of administration is crucial for survival, outcomes recommend.
Presenting the examine on the European Coronary heart Rhythm Affiliation (EHRA) 2023 congress in Barcelona, Prof Roland Tilz, MD, of the College Coronary heart Heart in Lübeck, Germany, stated, “I promise you that you should have a really clear plan find out how to diagnose and deal with sufferers with esophageal fistula after getting seen this presentation.”
This multinational (214 facilities in 35 international locations), retrospective examine amassed knowledge on 553,729 anonymized procedures. Investigators recognized 138 sufferers with atrial-esophageal or esophageal-pericardial fistula or esophageal perforation; the incidence was 0.025%, or roughly 25 per 100,000 sufferers.
There have been no exclusion standards for examine entry. Knowledge had been accessible for 118 circumstances and had been collected on-line on a person affected person stage utilizing a standardized, uniform questionnaire.
Delays in Prognosis
The time to first signs was a median of 18 days (95% CI, 7.75 – 25 days; vary, 0 – 60 days). Prognosis took a median of 21 days (95% CI, 15 – 29.5 days; vary, 2 – 63 days) after the ablation process. The most typical preliminary symptom was fever (59.3%), adopted by chest ache/odynophagia (54.2%) and neurologic indicators (44.1%).
The most typical diagnostic modalities had been chest CT (80.2%), cerebral CT/MRI (34.5%), echocardiography (25%), and endoscopy (20.7%). The most typical remedy methodology was surgical procedure (47.4%).
Loss of life occurred in 65.8% of circumstances, main/minor sequelae in 18.8%, and no sequelae in 15.4%. Issues consisted of extreme sepsis or septic shock (57.9%), coma (46.7%), stroke/cerebral hemorrhage (23.4%), cardiac arrest (18.7%), gastrointestinal bleeding (16.8%), cardiac tamponade (11.2%), and others.
Among the many remedy methods, surgical procedure was related to the bottom mortality price, lowering the danger of loss of life by about 68% (mortality odds ratio, 0.321), however even with surgical procedure, 51.9% of sufferers died.
Desk. Esophageal Fistula Remedy Outcomes
| Remedy | Mortality odds ratio (95% CI) | P worth | Loss of life (%) | Main sequelae (%) | Minor sequelae (%) | No sequelae (%) |
|---|---|---|---|---|---|---|
| Surgical procedure (47.4%) | 0.321 (0.144 – 0.714) | .005 | 51.9 | 16.7 | 16.7 | 14.8 |
| Endoscopic remedy (19.8%) | 0.629 (0.248 – 1.598) | .330 | 56.5 | 4.3 | 8.7 | 30.4 |
| Conservative administration (32.8%) | 7.463 (2.414 – 23.072) | < .001 | 89.5 | 2.6 | ― | 7.9 |
Tilz famous {that a} limitation of the examine is that it was retrospective, incorporating data on sufferers with current periprocedural EF. Subsequently, danger components for EF couldn’t be discerned. Moreover, if some occurrences of EF weren’t reported, the true incidence couldn’t be identified and could also be even larger.
Additionally, there have been no knowledge on procedural variables, comparable to esophageal temperature, and there have been no subgroup analyses based mostly on kind of catheter used, lesion parameters, lesion measurement, and ablation index.
He stated he performed a small Twitter survey of colleagues to get some extra real-world knowledge, asking, “What’s your first-line remedy for a affected person with confirmed atrial-esophageal fistula presenting with fever however and not using a neurologic deficit, so at an early stage?”
Whereas the bulk really useful surgical procedure, “I used to be actually shocked to listen to that just about 30% stated they suggest a conservative remedy,” he stated. “For those who deal with the affected person conservatively as really useful…within the Twitter survey, you’ve a 90% mortality price.”
The diagnostic modality of alternative was chest CT, which was diagnostic greater than 80% of the time, he stated. “So, with a chest CT and or cerebral CT or MRI, you would nearly determine it within the majority or nearly all sufferers.”
Half a Million Circumstances
Because the appointed discussant, Stylianos Tzeis, MD, PhD, head of the Cardiology Clinic and Electrophysiology and Pacing Division at Mitera Hospital in Athens, commented on the POTTER AF examine within the context of the general area, saying that the greater than half 1,000,000 circumstances enrolled “are greater than the variety of the inhabitants in all of the earlier surveys.”
He highlighted the truth that the incidence of EF, “regardless of our technological developments, stays secure and not using a important lower in pattern, is one thing about 0.02 or 0.03%, nearly three circumstances each 10,000 ablations,” with extraordinarily excessive mortality.
Tzeis attributed the complication to make use of of RF power, with “considerably decrease” danger with cryo power as in comparison with RF ablation. He famous that the danger of those problems will not be related to the amount of procedures of the middle or of operator expertise.
As a result of the examine is a survey, he raised among the typical caveats and limitations, two being the retrospective design and voluntary participation within the survey, so the pattern will not be consultant of physicians performing ablations. Even when there was underreporting and thus an underestimate of the incidence of EF, “it’s the greatest knowledge that we have now in our arms,” Tzeis stated.
Tilz has acquired analysis grants from Abbott Medical, Medtronic, Lifetech, Boston Scientific, and Biosense Webster; journey grants from Biosense Webster, Abbott Medical, Medtronic, and Boston Scientific; speaker’s bureau honoraria from Biosense Webster, Medtronic, Lifetech, Boston Scientific, Abbott Medical, Biotronik, Pfizer, Bristol-Myers Squibb, Bayer, and Sanofi-Aventis; and publication charges from Boston Scientific. He has served as a guide to Biosense Webster, Biotronik, Boston Scientific, and Abbott Medical. Tzeis reported no related monetary relationships.
European Coronary heart Rhythm Affiliation (EHRA) 2023: Offered April 16, 2023.
For extra information, observe Medscape on Facebook, Twitter, Instagram, and YouTube.