Global Survey of Esophageal Injury in Atrial Fibrillation Ablation: Characteristics and Outcomes of Esophageal Perforation and Fistula

Chirag R. Barbhaiya; Saurabh Kumar; Yu Guo; Judy Zhong; Roy M. John; Usha B. Tedrow; Bruce A. Koplan; Laurence M. Epstein; William G. Stevenson; Gregory F. Michaud

doi:10.1016/j.jacep.2015.10.013

JACC: Clinical Electrophysiology

Volume 2, Issue 2, April 2016 DOI: 10.1016/j.jacep.2015.10.013

Global Survey of Esophageal Injury in Atrial Fibrillation Ablation
Characteristics and Outcomes of Esophageal Perforation and Fistula

Chirag R. Barbhaiya, Saurabh Kumar, Yu Guo, Judy Zhong, Roy M. John, Usha B. Tedrow, Bruce A. Koplan, Laurence M. Epstein, William G. Stevenson and Gregory F. Michaud

Author + information

vol. 2 no. 2 143-150

DOI:

https://doi.org/10.1016/j.jacep.2015.10.013

Published By:

JACC: Clinical Electrophysiology

Print ISSN:

2405-5018

Online ISSN:

2405-500X

History:

Received July 27, 2015
Revision received October 1, 2015
Accepted October 22, 2015
Published online April 1, 2016.

2016 American College of Cardiology Foundation

Author Information

Chirag R. Barbhaiya, MD^a,^∗ (chirag.barbhaiya{at}nyumc.org),
Saurabh Kumar, BSc [Med], MBBS, PhD^b,
Yu Guo, MA^c,
Judy Zhong, PhD^c,
Roy M. John, MD, PhD^b,
Usha B. Tedrow, MD, MSc^b,
Bruce A. Koplan, MD, MPH^b,
Laurence M. Epstein, MD^a,
William G. Stevenson, MD^b and
Gregory F. Michaud, MD^a

^aLeon H. Charney Division of Cardiology, New York University Langone Medical Center, New York, New York
^bCardiovascular Division, Brigham and Women’s Hospital, Boston, Massachusetts
^cDivision of Biostatistics, Department of Population Health, New York University School of Medicine, New York, New York

↵∗Reprint requests and correspondence:
Dr. Chirag R. Barbhaiya, Leon H. Charney Division of Cardiology, New York University School of Medicine, 550 1st Avenue, New York, New York 10016.

Abstract

Objectives This study sought to assess the incidence, operator demographics, clinical characteristics, procedural factors, and prognosis of esophageal perforation and fistula after atrial fibrillation ablation.

Background Esophageal injury is a feared complication of atrial fibrillation ablation.

Methods An Internet-based global survey soliciting anonymous information regarding esophageal perforation and fistula was emailed to 3,080 physicians. Detailed information regarding physician, patient, and procedural characteristics related to esophageal perforation with or without fistula was collected.

Results The survey was completed by 405 of 3,080 physicians (13%). Responding physicians performed 191,215 atrial fibrillation ablations and esophageal perforation with or without fistula occurred in 31 patients (0.016%) with multiple ablation catheter types despite monitoring of esophageal position or temperature during ablation in 90% of patients. Among patients who present with esophageal perforation, death, or severe neurologic injury occurred more frequently in patients with greater body mass index (30.9 ± 6.8 kg/m² vs. 25.8 ± 3.3 kg/m²; p = 0.03), and lower left ventricular ejection fraction (55.1 ± 9.1% vs. 61.7 ± 5.4%; p = 0.04). Among analyzed patients, atrial-esophageal fistula was seen in 72%, pericardial-esophageal fistula in 14%, and esophageal perforation without fistula in 14%. Mortality was 79% with atrial-esophageal fistula and 13% in esophageal perforation without atrial-esophageal fistula.

Conclusions Esophageal perforation is rare but continues to occur with multiple catheter types despite esophageal monitoring during ablation. The prognosis of esophageal perforation is substantially improved if diagnosed and treated before development of atrial-esophageal fistula. An early surgical approach to esophageal perforation should be strongly considered regardless of evidence of fistula.

Key Words

Footnotes

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. John receives consulting fees/honoraria from St. Jude Medical and Boston Scientific Inc.; and is a consultant for Biosense Webster, Inc. Dr. Tedrow receives consulting fees/honoraria from Boston Scientific Corp. and St. Jude Medical; and research funding from Biosense Webster, Inc., and St. Jude Medical. Dr. Epstein receives consulting fees/honoraria from Boston Scientific Corp., St. Jude Medical, Medtronic, Inc., and Spectranetics Corp. Dr. Michaud receives consulting fees/honoraria from Boston Scientific Corp., Medtronic, 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.
Listen to this manuscript's audio summary by JACC: Clinical Electrophysiology Editor-in-Chief Dr. David J. Wilber.