Author + information
- Chirag R. Barbhaiya, MD∗ (, )
- Saurabh Kumar, BSc [Med]/MBBS, PhD,
- Roy M. John, MD, PhD,
- Usha B. Tedrow, MD, MSc,
- Bruce A. Koplan, MD, MPH,
- Laurence M. Epstein, MD,
- William G. Stevenson, MD and
- Gregory F. Michaud, MD
- ↵∗Brigham and Women’s Hospital, 75 Francis Street, Boston, Massachusetts 02115
Catheter ablation of the left atrial (LA) posterior wall may result in esophageal injury ranging from mild erythema to ulceration and, in rare but devastating cases, esophageal perforation or fistula (1). In addition, vagus nerve damage can result in gastric hypomotility and gastroparesis (2). There are limited data regarding the incidence and outcomes of these complications.
We circulated an online survey to the 3080 registered physician members of the Heart Rhythm Society, as well as all physicians who perform atrial fibrillation (AF) ablation. We collected responses between November 1, 2013 and June 1, 2014. Of the 3080 physicians who received the survey, 405 responded (13%). In aggregate, 191,215 AF ablations were performed by responding physicians, and esophageal perforation or fistula was reported in 31 patients (0.016%) by responding physicians 30 (7%).
Gastroparesis was reported in 63 patients by 47 physicians. The mean postoperative day (POD) of diagnosis was 5.7 ± 5.8 days, and gastroparesis symptoms resolved completely in 59 patients (94%). Patients in whom gastroparesis did not completely resolve received the diagnosis at a significantly later POD compared with patients whose symptoms resolved completely (15.3 ± 6.2 vs. 5.0 ± 5.2; p < 0.001) (Figure 1).
Esophageal ulcer was reported in 51 patients, of whom 37 (73%) had complete resolution of ulcer symptoms. Patients whose esophageal ulcer symptoms did not completely resolve received the diagnosis at a significantly later POD than patients with complete symptom resolution (16.2 ± 4.3 vs. 2.9 ± 3.1; p < 0.001) (Figure 1).
Symptom onset for esophageal perforation or fistula was reported on POD 19.3 ± 12.6 (range, 6 to 59 days) (Figure 1). Of the 28 patients with esophageal perforation or fistula for whom detailed information was provided, 20 (71%) had an atrial-esophageal fistula (AEF), 4 (14%) a pericardial-esophageal fistula, and 4 (14%) esophageal perforation without fistula formation. Of these 28 patients, a significantly greater proportion of those who died or had severe neurological injury ultimately received a diagnosis of AEF (94% vs. 36%; p = 0.002). All patients with AEF who survived without severe neurological injury underwent thoracic surgery. Two patients (7%) in whom an AEF developed died after AF ablation with a second-generation cryoballoon procedure.
The present survey—the largest dataset of gastroesophageal injury in AF ablation to date—demonstrates that gastroparesis, esophageal ulcer, and esophageal perforation occur in a bimodal temporal distribution of injury; spontaneously resolving injury presents primarily in the first several days post-ablation, and more severe injury primarily after 10 days. Proposed mechanisms for esophageal injury include direct thermal injury, which may account for early symptoms, and ischemic injury, which may account for later, more severe injury (3).
In a previous global survey of complications related to AF ablation performed from 2003 to 2006, Cappato et al. (4) reported a 0.04% rate of AEF. In a national survey performed from 2004 to 2005 by Ghia et al. (5), AEF occurred in 0.03% of patients in a cohort of 20,425. The incidence of esophageal perforation without fistula formation and pericardial-esophageal fistula was not reported in either previous survey. The 0.016% incidence of esophageal perforation and 0.011% incidence of AEF in the present study are both significantly lower (p < 0.001) than the incidence of AEF reported in the previous surveys, and the total number of AF ablations performed by survey physicians is greater than in previous studies, suggesting that the risk of esophageal perforation with AF ablation may now be lower than previously reported.
Self-selection bias is a limitation of survey-based data. Physicians retrospectively reported all data, and inaccurate responses due to poor recall were not excluded. Given the observational nature of the study, it is impossible to determine causation versus correlation.
We observed a bimodal temporal distribution of gastroesophageal injury after AF ablation, and all gastroparesis and esophageal injury diagnosed in the first 5 days after ablation resolved spontaneously. Symptom onset of gastric and esophageal injury more than 5 days after AF ablation is concerning for more severe injury. Our data reinforce the importance of close postoperative follow-up after AF ablation, even if patients do not report symptoms in the first few days after ablation of the posterior LA wall.
Please note: Dr. Kumar is a recipient of the Neil Hamilton Fairley Overseas Research scholarship cofunded by the National Health and Medical Research Council and the National Heart Foundation of Australia; and the Bushell Travelling Fellowship funded by the Royal Australasian College of Physicians. Dr. Tedrow has received consulting fees/honoraria from Boston Scientific Corp. and St. Jude Medical; and research funding from Biosense Webster, Inc. and St. Jude Medical. Dr. John has received consulting fees/honoraria from St. Jude Medical, Medtronic, and Boston Scientific. Dr. Koplan is a consultant for St. Jude Medical and Boston Scientific. Dr. Epstein is a consultant and speaker for Boston Scientific Corp., Medtronic, Inc., and Spectranetics Corp. Dr. Michaud has received consulting fees/honoraria from Boston Scientific Corp., Medtronic, Inc., AtriCure, Inc., and St. Jude Medical; and research funding from Boston Scientific Corp., and Biosense Webster, Inc. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
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