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. 2023 Jul 14;44(27):2458-2469.
doi: 10.1093/eurheartj/ehad250.

A worldwide survey on incidence, management, and prognosis of oesophageal fistula formation following atrial fibrillation catheter ablation: the POTTER-AF study

Roland Richard Tilz  1   2 , Vanessa Schmidt  1 , Helmut Pürerfellner  3 , Philippe Maury  4 , K R J Ulian Chun  5 , Martin Martinek  3 , Christian Sohns  6 , Boris Schmidt  5 , Franck Mandel  4 , Estelle Gandjbakhch  7 , Mikael Laredo  8 , Melanie Anuscha Gunawardene  9 , Stephan Willems  9 , Thomas Beiert  10 , Martin Borlich  11 , Leon Iden  11 , Anna Füting  12   13 , Raphael Spittler  14 , Thomas Gaspar  15 , Sergio Richter  15 , Anja Schade  16 , Malte Kuniss  17 , Thomas Neumann  17 , Alexander Francke  18 , Carsten Wunderlich  18 , Dong-In Shin  19   20 , Dirk Grosse Meininghaus  21 , Mike Foresti  22 , Marc Bonsels  22 , David Reek  23 , Uwe Wiegand  24 , Alexander Bauer  25 , Andreas Metzner  26 , Lars Eckardt  27 , Sorin Ștefan Popescu  1 , Olaf Krahnefeld  28 , Christian Sticherling  29 , Michael Kühne  29 , Dinh Quang Nguyen  30 , Laurent Roten  31 , Ardan M Saguner  32 , Dominik Linz  33 , Pepijn van der Voort  34 , Bart A Mulder  35 , Johan Vijgen  36 , Alexandre Almorad  37 , Charles Guenancia  38 , Laurent Fauchier  39 , Serge Boveda  40   37 , Y De Greef  41   37 , Antoine Da Costa  42 , Pierre Jais  43 , Nicolas Derval  43 , Antoine Milhem  44 , Laurence Jesel  45 , Rodrigue Garcia  46 , Hervé Poty  47 , Ziad Khoueiry  48 , Julien Seitz  49 , Julien Laborderie  50 , Alexis Mechulan  51 , Francois Brigadeau  52 , Alexandre Zhao  53 , Yannick Saludas  54 , Olivier Piot  55 , Nikhil Ahluwalia  56   57 , Claire Martin  58 , Jian Chen  59 , Bor Antolic  60 , Georgios Leventopoulos  61 , Emin Evren Özcan  62 , Hikmet Yorgun  63 , Serkan Cay  64 , Kivanc Yalin  65 , Maichel Sobhy Botros  66 , Ahmed Taher Mahmoud  66 , Ewa Jędrzejczyk-Patej  67 , Osamu Inaba  68 , Ken Okumura  69 , Koichiro Ejima  70 , Houman Khakpour  71 , Noel Boyle  71 , John N Catanzaro  72 , Vivek Reddy  73 , Sanghamitra Mohanty  74 , Andrea Natale  74   75   76 , Hermann Blessberger  77 , Bing Yang  78 , Irene Stevens  1 , Philipp Sommer  6 , Christian Veltmann  79 , Daniel Steven  80 , Julia Vogler  1 , Karl-Heinz Kuck  1 , José Luis Merino  81 , Ahmad Keelani  1 , Christian-H Heeger  1   2
Affiliations

A worldwide survey on incidence, management, and prognosis of oesophageal fistula formation following atrial fibrillation catheter ablation: the POTTER-AF study

Roland Richard Tilz et al. Eur Heart J. .

Abstract

Aims: Oesophageal fistula represents a rare but dreadful complication of atrial fibrillation catheter ablation. Data on its incidence, management, and outcome are sparse.

Methods and results: This international multicentre registry investigates the characteristics of oesophageal fistulae after treatment of atrial fibrillation by catheter ablation. A total of 553 729 catheter ablation procedures (radiofrequency: 62.9%, cryoballoon: 36.2%, other modalities: 0.9%) were performed, at 214 centres in 35 countries. In 78 centres 138 patients [0.025%, radiofrequency: 0.038%, cryoballoon: 0.0015% (P < 0.0001)] were diagnosed with an oesophageal fistula. Peri-procedural data were available for 118 patients (85.5%). Following catheter ablation, the median time to symptoms and the median time to diagnosis were 18 (7.75, 25; range: 0-60) days and 21 (15, 29.5; range: 2-63) days, respectively. The median time from symptom onset to oesophageal fistula diagnosis was 3 (1, 9; range: 0-42) days. The most common initial symptom was fever (59.3%). The diagnosis was established by chest computed tomography in 80.2% of patients. Oesophageal surgery was performed in 47.4% and direct endoscopic treatment in 19.8% and conservative treatment in 32.8% of patients. The overall mortality was 65.8%. Mortality following surgical (51.9%) or endoscopic treatment (56.5%) was significantly lower as compared to conservative management (89.5%) [odds ratio 7.463 (2.414, 23.072) P < 0.001].

Conclusion: Oesophageal fistula after catheter ablation of atrial fibrillation is rare and occurs mostly with the use of radiofrequency energy rather than cryoenergy. Mortality without surgical or endoscopic intervention is exceedingly high.

Keywords: Atrial fibrillation; Catheter ablation; Oesophageal fistula; Radiofrequency energy.

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Conflict of interest statement

Conflict of interest R.R.T. is a consultant for Boston Scientific, Biotronik, and Biosense Webster and received speaker honoraria from Biosense Webster, Medtronic, Boston Scientific, and Abbot Medical. K.-H.K. reports grants and personal fees from Abbott Vascular, Medtronic, Biosense Webster, outside the submitted work. C.H.H. received travel grants and research grants from Boston Scientific, Lifetech, Biosense Webster, and Cardiofocus and speaker honoraria from Medtronic, Boston Scientific, Biosense Webster, Cardiofocus and C.T.I. GmbH and Doctrina Med. He is a consultant of Boston Scientific, Lifetech, Biosense Webster, and Cardiofocus. H.P.—receipt of honoraria or consultation fees: Bayer, Daiichi-Sankyo, Boehringer-Ingelheim, Pfizer, Abbott, Biosense-Webster, Boston Scientific, and Medtronic; participation in a company sponsored speaker’s bureau: Biosense Webster, Abbott, Medtronic, Boston. M.M.—consultant and speaker: Abbott Medical, Biosense Webster, Medtronic, and Boston Scientific. P.S.—advisory Board für Biosense Webster, Boston Scientific, Abbott, und Medtronic. C.S. received research support and lecture fees from Medtronic, Abbott, Boston Scientific, and Biosense Webster. In addition, C.S. is a consultant for Medtronic, Boston Scientific, and Biosense Webster. C.V.—honoraria for training and consulting: Biotronik, Medtronic EG Unrelated to the topic: consulting fees from Medtronic, Boston, Microport, Abbott MG Speaker‘s honoraria/travel grants: Abbott, Biosense Webster, Boston Scientific, Medtronic, and Farapulse Inc. S.W.—consulting fees, Abbott, Biosense Webster, Boston Scientific, Bristol Myers Squibb, Boehringer Ingelheim, Medtronic, and Daiichi. Grants: Abbott, Boston Scientific. M.B. has received consultant honoraria and/or lecture honoraria and/or and travel grants from: Bayer, Novartis, Biosense Webster, Biotronik, and Boston Scientific. The following applies to both authors: there are no conflicts of interest with regard to this publication. L.I. has received consultant honoraria and/or lecture honoraria and/or and travel grants from: Abbott Medical, Bayer, Berlin-Chemie, Biosense Webster, Biotronik, Bristol-Myers-Squibb, Daiichi-Sankyo, Medtronic, and Novartis. A.F.—educational grant from Boston Scientific. S.R.—consultant for Medtronic, Abbott, and Biotronik, Member of the Medtronic European Conduction System Pacing Advisory Board. M.K.—honoraria for teaching, proctoring and lectures, honoraria for advisory board activities, participation in clinical trials, travel grants. A.F.—lecture fees and Consultant für Biosense Webster. C.W.—lecture fees from Biosense Webster. U.W.—lecture fees from Abbott Medical und Medtronic Inc. A.M.—consultant fees: Medtronic, CardioFocus, Biosense-Webster, and Boston Scientific. Travel grants and lecture honoraria: Medtronic, Cardiofocus, Biosense-Webster, Boston Scientific, Lifetech, AstraZeneca, Boehringer Ingelheim, Bayer, and Philips-EPD. L.E.—discloses consultant fees, speaking honoraria, and travel expenses from Abbott, Bayer Healthcare, Biosense Webster, Biotronik, Boehringer, Boston Scientific, Bristol-Myers Squibb, Daiichi Sankyo, Medtronic, Pfizer, and Sanofi Aventis. Research has been supported by German Research Foundation (DFG) and German Heart Foundation outside the submitted work. C.S. reports grants and lecture fees from Biosense Webster and Medtronic and served as a proctor for Biosense Webster and Medtronic. He also reports grants from the Swiss Heart Foundation, the Foundation for Cardiovascular Research Basel, and the University of Basel. M.K. reports grants from the Swiss National Science Foundation (Grant numbers 33CS30_148474, 33CS30_177520, 32473B_176178, 32003B_197524), the Swiss Heart Foundation, the Foundation for Cardiovascular Research Basel and the University of Basel, grants from Bayer, grants from Pfizer, grants from Boston Scientific, grants from BMS, grants from Biotronik, grants and personal fees from Daiichi Sankyo. L.R. has received speaker/consulting honoraria from Abbott/SJM and from Medtronic and has received a research grant for an investigator-initiated study to the institution from Medtronic. A.M.S. received educational grants through his institution from Abbott, Bayer Healthcare, Biosense Webster, Biotronik, Boston Scientific, BMS/Pfizer, and Medtronic; and speaker/advisory board/consulting fees from Bayer Healthcare, Biotronik, Daiichi-Sankyo, Medtronic, Novartis, Pfizer and Stride Bio Inc. C.G.—research grants: MicroPort CRM. Consultant: MicroPort CRM, Boston Scientific, Abbott, Medtronic. Honoraria: Biotronik, Medtronic, Astra-Zeneca, BMS-Pfizer, Biosense-Webster. L.F. reports consulting fees for AstraZeneca, Bayer, BMS/Pfizer, Boehringer Ingelheim, Medtronic, Novo Nordisk, and Novartis and lecture fees for AstraZeneca, Bayer, BMS/Pfizer, Boehringer Ingelheim and Zoll. S.B.—consultant for Medtronic, Boston Scientific, Microport, and Zoll. N.L.—consulting fees for Abbott Medtronic and Boston Scientific PJ Grant from Biosense Webster, Metronic, ABBOTT, Boston. N.D. consultant for Biosense Webster. C.M. BSCI, Medtronic, Biosense Webster, Adagio—speaker honoraria and consultancy fees. P.H. BSCI and Medtronic—speaker honoraria. J.C. serves as a consultant for Biosense Webster, Johnson & Johnson. G.L.—In general, I have received funding from Biosense Webster, Medtronic, and Abbott (speaker honoraria). E.E.Ö.—payment from healthcare industry to my institution for my personal services: honoraria, consultancy, advisory board: Biosense Webster, Medtronic. H.Y.—proctor for Abbott, Medtronic, and Biosense Webster. S.C.—travel grants and speaker’s honoraria from Medtronic, Biosense Webster, and Abbott and is a proctor of Medtronic and Biotronik. E.J.—consultant fees from Biotronik, Medtronic, Abbott, Boston Scientific. K.O. received remuneration from Nippon Boehringer Ingelheim, Daiichi Sankyo, Johnson & Johnson, and Medtronic. J.N.C. Circa Scientific: research support. V.Y.R. does not report any disclosures directly related to this manuscript; but unrelated to this manuscript, he has served as a consultant for and has equity in Ablacon, Acutus Medical, Affera-Medtronic, Anumana, Apama Medical-Boston Scientific, APN Health, Aquaheart, Atacor, Autonomix, Axon Therapies, Backbeat, BioSig, CardiaCare, CardioNXT/AFTx, Circa Scientific, CoRISMA, Corvia Medical, Dinova-Hangzhou DiNovA EP Technology, East End Medical, EPD-Philips, EP Frontiers, Epix Therapeutics-Medtronic, EpiEP, Eximo, Farapulse-Boston Scientific, Field Medical, Focused Therapeutics, HRT, Intershunt, Javelin, Kardium, Keystone Heart, LuxMed, Medlumics, Middlepeak, Neutrace, Nuvera-Biosense Webster, Oracle Health, Restore Medical, Sirona Medical, SoundCath, Valcare; unrelated to this work, has served as a consultant for Abbott, AtriAN, Biosense-Webster, BioTel Heart, Biotronik, Boston Scientific, Cairdac, Cardiofocus, Cardionomic, CoreMap, Fire1, Gore & Associates, Impulse Dynamics, Medtronic, Novartis, Philips, Pulse Biosciences; and has equity in Manual Surgical Sciences, Newpace, Nyra Medical, Surecor, and Vizaramed’. A.N. consultant for Abbott, Baylis, biosense webster, biotronik, boston scientific and Medtronic DS research grant: Abbott, Medtronic, Johnson&Johnson; advisory board: Pfizer, Abbott; speaker fee: Abbott, Medtronic, Johnson&Johnson. J.L.M. received speaker fees and/or honoraria for lectures and scientific advice from Biotronik, Medtronic, Microport, Milestone Pharmaceutical, Sanofi, and Zoll. K.H.K. reports grants and personal fees from Abbott Vascular, Medtronic, Biosense Webster outside submitted work. All other authors have no relevant disclosures.

Figures

Structured Graphical Abstract
Structured Graphical Abstract
Summary of the POTTER-AF study results. CI, confidence interval; OR, odds ratio.
Figure 1
Figure 1
Flowchart of the POTTER-AF study. AF, atrial fibrillation; OF, oesophageal fistula; CT, computed tomography.
Figure 2
Figure 2
(A) Endoscopic view of the oesophagus in a patient with an atrio-oesophageal fistula. (B) Intraoperative situ during oesophageal surgery in a patient with an atrio-oesophageal fistula.
Figure 3
Figure 3
(A) Time to first symptoms and time to diagnosis. Overview of the clinical presentation (B), utilized diagnostic modalities (C), and complications (D) of all patients with oesophageal fistula (n = 118). Multiple symptoms were possible.
Figure 4
Figure 4
(A) Overview of the different treatment strategies and outcome of patients. (B) Outcome of all patients with oesophageal fistula.
See this image and copyright information in PMC

Comment in

References

    1. Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, et al. . 2020 ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS): the task force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC). Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J 2021;42:373–498. 10.1093/eurheartj/ehaa612 - DOI - PubMed
    1. Ghia KK, Chugh A, Good E, Pelosi F, Jongnarangsin K, Bogun F, et al. . A nationwide survey on the prevalence of atrioesophageal fistula after left atrial radiofrequency catheter ablation. J Interv Card Electrophysiol 2008;24:33–36. 10.1007/s10840-008-9307-1 - DOI - PubMed
    1. Gandjbakhch E, Mandel F, Dagher Y, Hidden-Lucet F, Rollin A, Maury P. Incidence, epidemiology, diagnosis and prognosis of atrio-oesophageal fistula following percutaneous catheter ablation: a French nationwide survey. Europace 2021;23:557–564. 10.1093/europace/euaa278 - DOI - PubMed
    1. Cappato R, Calkins H, Chen S-A, Davies W, Iesaka Y, Kalman J, et al. . Updated worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circ Arrhythm Electrophysiol 2009;3:32–38. 10.1161/CIRCEP.109.859116 - DOI - PubMed
    1. Chavez P, Messerli FH, Dominguez AC, Aziz EF, Sichrovsky T, Garcia D, et al. . Atrioesophageal fistula following ablation procedures for atrial fibrillation: systematic review of case reports. Open Heart 2015;2:e000257. 10.1136/openhrt-2015-000257 - DOI - PMC - PubMed