Atrioesophageal Fistula: Clinical Presentation, Procedural Characteristics, Diagnostic Investigations, and Treatment Outcomes

Hui Chen Han, Francis J. Ha, Prash Sanders, Ryan Spencer, Andrew W. Teh, David O'Donnell, Omar Farouque, Han S. Lim

Research output: Contribution to journalReview article

14 Citations (Scopus)

Abstract

BACKGROUND: Percutaneous or surgical ablation are increasingly used worldwide in the management of atrial fibrillation. The development of atrioesophageal fistula (AEF) is among the most serious and lethal complications of atrial fibrillation ablation. We sought to characterize the clinical presentation, procedural characteristics, diagnostic investigations, and treatment outcomes of all reported cases of AEF.

METHODS AND RESULTS: Electronic searches were conducted in PubMed and Embase for English scientific literature articles. Out of 628 references, 120 cases of AEF were identified using various ablation modalities. Clinical presentation occurred between 0 and 60 days postablation (median 21 days). Fever (73%), neurological (72%), gastrointestinal (41%), and cardiac (40%) symptoms were the commonest presentations. Computed tomography of the chest was the commonest mode of diagnosis (68%), although 7 cases required repeat testing. Overall mortality was 55%, with significantly reduced mortality in patients undergoing surgical repair (33%) compared with endoscopic treatment (65%) and conservative management (97%) (adjusted odds ratio, 24.9; P<0.01, compared with surgery). Multivariable predictors of mortality include presentation with neurological symptoms (adjusted odds ratio, 16.0; P<0.001) and gastrointestinal bleed (adjusted odds ratio, 4.2; P=0.047).

CONCLUSIONS: AEF complicating atrial fibrillation ablation is associated with a high mortality. Clinicians should have a high suspicion for the development of AEF in patients presenting with infective, neurological, gastrointestinal, or cardiac symptoms within 2 months of an atrial fibrillation ablation. Investigation by contrast computed tomography of the chest with consideration of repeat testing can lead to prompt diagnosis. Surgical intervention is associated with improved survival rates.

LanguageEnglish
JournalCirculation. Arrhythmia and electrophysiology
Volume10
Issue number11
DOIs
Publication statusPublished - 1 Nov 2017

Keywords

  • atrial fibrillation
  • esophageal fistula
  • safety
  • survival rate
  • treatment outcome

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)

Cite this

Han, Hui Chen ; Ha, Francis J. ; Sanders, Prash ; Spencer, Ryan ; Teh, Andrew W. ; O'Donnell, David ; Farouque, Omar ; Lim, Han S. / Atrioesophageal Fistula : Clinical Presentation, Procedural Characteristics, Diagnostic Investigations, and Treatment Outcomes. In: Circulation. Arrhythmia and electrophysiology. 2017 ; Vol. 10, No. 11.
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title = "Atrioesophageal Fistula: Clinical Presentation, Procedural Characteristics, Diagnostic Investigations, and Treatment Outcomes",
abstract = "BACKGROUND: Percutaneous or surgical ablation are increasingly used worldwide in the management of atrial fibrillation. The development of atrioesophageal fistula (AEF) is among the most serious and lethal complications of atrial fibrillation ablation. We sought to characterize the clinical presentation, procedural characteristics, diagnostic investigations, and treatment outcomes of all reported cases of AEF.METHODS AND RESULTS: Electronic searches were conducted in PubMed and Embase for English scientific literature articles. Out of 628 references, 120 cases of AEF were identified using various ablation modalities. Clinical presentation occurred between 0 and 60 days postablation (median 21 days). Fever (73{\%}), neurological (72{\%}), gastrointestinal (41{\%}), and cardiac (40{\%}) symptoms were the commonest presentations. Computed tomography of the chest was the commonest mode of diagnosis (68{\%}), although 7 cases required repeat testing. Overall mortality was 55{\%}, with significantly reduced mortality in patients undergoing surgical repair (33{\%}) compared with endoscopic treatment (65{\%}) and conservative management (97{\%}) (adjusted odds ratio, 24.9; P<0.01, compared with surgery). Multivariable predictors of mortality include presentation with neurological symptoms (adjusted odds ratio, 16.0; P<0.001) and gastrointestinal bleed (adjusted odds ratio, 4.2; P=0.047).CONCLUSIONS: AEF complicating atrial fibrillation ablation is associated with a high mortality. Clinicians should have a high suspicion for the development of AEF in patients presenting with infective, neurological, gastrointestinal, or cardiac symptoms within 2 months of an atrial fibrillation ablation. Investigation by contrast computed tomography of the chest with consideration of repeat testing can lead to prompt diagnosis. Surgical intervention is associated with improved survival rates.",
keywords = "atrial fibrillation, esophageal fistula, safety, survival rate, treatment outcome",
author = "Han, {Hui Chen} and Ha, {Francis J.} and Prash Sanders and Ryan Spencer and Teh, {Andrew W.} and David O'Donnell and Omar Farouque and Lim, {Han S.}",
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Atrioesophageal Fistula : Clinical Presentation, Procedural Characteristics, Diagnostic Investigations, and Treatment Outcomes. / Han, Hui Chen; Ha, Francis J.; Sanders, Prash; Spencer, Ryan; Teh, Andrew W.; O'Donnell, David; Farouque, Omar; Lim, Han S.

In: Circulation. Arrhythmia and electrophysiology, Vol. 10, No. 11, 01.11.2017.

Research output: Contribution to journalReview article

TY - JOUR

T1 - Atrioesophageal Fistula

T2 - Circulation: Arrhythmia and Electrophysiology

AU - Han, Hui Chen

AU - Ha, Francis J.

AU - Sanders, Prash

AU - Spencer, Ryan

AU - Teh, Andrew W.

AU - O'Donnell, David

AU - Farouque, Omar

AU - Lim, Han S.

PY - 2017/11/1

Y1 - 2017/11/1

N2 - BACKGROUND: Percutaneous or surgical ablation are increasingly used worldwide in the management of atrial fibrillation. The development of atrioesophageal fistula (AEF) is among the most serious and lethal complications of atrial fibrillation ablation. We sought to characterize the clinical presentation, procedural characteristics, diagnostic investigations, and treatment outcomes of all reported cases of AEF.METHODS AND RESULTS: Electronic searches were conducted in PubMed and Embase for English scientific literature articles. Out of 628 references, 120 cases of AEF were identified using various ablation modalities. Clinical presentation occurred between 0 and 60 days postablation (median 21 days). Fever (73%), neurological (72%), gastrointestinal (41%), and cardiac (40%) symptoms were the commonest presentations. Computed tomography of the chest was the commonest mode of diagnosis (68%), although 7 cases required repeat testing. Overall mortality was 55%, with significantly reduced mortality in patients undergoing surgical repair (33%) compared with endoscopic treatment (65%) and conservative management (97%) (adjusted odds ratio, 24.9; P<0.01, compared with surgery). Multivariable predictors of mortality include presentation with neurological symptoms (adjusted odds ratio, 16.0; P<0.001) and gastrointestinal bleed (adjusted odds ratio, 4.2; P=0.047).CONCLUSIONS: AEF complicating atrial fibrillation ablation is associated with a high mortality. Clinicians should have a high suspicion for the development of AEF in patients presenting with infective, neurological, gastrointestinal, or cardiac symptoms within 2 months of an atrial fibrillation ablation. Investigation by contrast computed tomography of the chest with consideration of repeat testing can lead to prompt diagnosis. Surgical intervention is associated with improved survival rates.

AB - BACKGROUND: Percutaneous or surgical ablation are increasingly used worldwide in the management of atrial fibrillation. The development of atrioesophageal fistula (AEF) is among the most serious and lethal complications of atrial fibrillation ablation. We sought to characterize the clinical presentation, procedural characteristics, diagnostic investigations, and treatment outcomes of all reported cases of AEF.METHODS AND RESULTS: Electronic searches were conducted in PubMed and Embase for English scientific literature articles. Out of 628 references, 120 cases of AEF were identified using various ablation modalities. Clinical presentation occurred between 0 and 60 days postablation (median 21 days). Fever (73%), neurological (72%), gastrointestinal (41%), and cardiac (40%) symptoms were the commonest presentations. Computed tomography of the chest was the commonest mode of diagnosis (68%), although 7 cases required repeat testing. Overall mortality was 55%, with significantly reduced mortality in patients undergoing surgical repair (33%) compared with endoscopic treatment (65%) and conservative management (97%) (adjusted odds ratio, 24.9; P<0.01, compared with surgery). Multivariable predictors of mortality include presentation with neurological symptoms (adjusted odds ratio, 16.0; P<0.001) and gastrointestinal bleed (adjusted odds ratio, 4.2; P=0.047).CONCLUSIONS: AEF complicating atrial fibrillation ablation is associated with a high mortality. Clinicians should have a high suspicion for the development of AEF in patients presenting with infective, neurological, gastrointestinal, or cardiac symptoms within 2 months of an atrial fibrillation ablation. Investigation by contrast computed tomography of the chest with consideration of repeat testing can lead to prompt diagnosis. Surgical intervention is associated with improved survival rates.

KW - atrial fibrillation

KW - esophageal fistula

KW - safety

KW - survival rate

KW - treatment outcome

UR - http://www.scopus.com/inward/record.url?scp=85033554259&partnerID=8YFLogxK

U2 - 10.1161/CIRCEP.117.005579

DO - 10.1161/CIRCEP.117.005579

M3 - Review article

VL - 10

JO - Circulation: Arrhythmia and Electrophysiology

JF - Circulation: Arrhythmia and Electrophysiology

SN - 1941-3149

IS - 11

ER -