The present study was approved by the Institutional Review Board of the French Society of Thoracic and Cardiovascular Surgery (CERC-SFCTCV-2023-04-25_28215)

## Background

Atrio-esophageal fistula (AEF) is the most feared and life-threatening complication after catheter ablation (CA) of atrial fibrillation (AF). Its incidence remains stable around **0.02 to 0.04%** despite technical improvement and novel energy sources over time with a high mortality rate (**55 to 65%**). Many therapeutic options have been described: medical or conservative treatment, endoscopic treatment alone or associated with surgery and upfront surgical treatment. Some authors have shown a clear benefit in survival of a surgical management for AEF in comparison to endoscopic or medical treatment alone. We aimed to compare different surgical strategies in the management of atrio-esophageal fistula.

## Objective

To compare the efficacy of different surgical strategies for AEF after catheter ablation of atrial fibrillation in a French survey.

## Methods

Between January 2010 and April 2023, all patients with a diagnosis of AEF or pericardo-esophageal fistula (PEF) after catheter ablation of atrial fibrillation were analyzed retrospectively from the French database EPITHOR. Patients without surgical management were excluded.

## Cohort

18 patients were included, 15 with AEF and 3 with PEF. Median follow-up was 89.5 days (mean follow-up 768.2 days) with an overall survival rate of 50%.

<figure><img src="image_1.png" /><figcaption>Figure 1. CT Chest scan with contrast esophagogram</figcaption></figure>

The yellow arrow shows a pericardo-esophageal fistula

<figure><img src="image_2.png" /><figcaption>Figure 2. Survival curve according to the use of esophagectomy</figcaption></figure>

Survival at 180 days

<figure><img src="image_3.png" /></figure>

Risk of death in multivariate analysis = SEPSIS (HR 6.25, 95% CI 1.17-33.3; p=0.032)

Surgical direct repair: 33%

Esophagectomy 86%

<table><caption>Table 1. Surgical strategies and outcomes</caption><thead><tr><th>N</th><th>Age</th><th>Sex</th><th>AOF sub-types</th><th>Imaging for diagnosis</th><th>Esophageal stenting</th><th>Surgical strategies</th><th>Complications</th><th>Restorative surgery</th><th>Vital Status</th><th>Cause of death</th></tr></thead><tbody><tr><td>1*</td><td>34</td><td>M</td><td>AEF</td><td>Chest CT</td><td>-</td><td>Sternotomy, CPB, LA patch repair, Esophagus direct suture, Flap interposition</td><td>Re Do surgery</td><td>-</td><td>Deceased</td><td>Multi-organ failure</td></tr><tr><td>2</td><td>72</td><td>M</td><td>PEF</td><td>EGD</td><td>-</td><td>Sternotomy, CPB, LA direct suture, Esophagus direct suture, Flap interposition</td><td>Re Do surgery</td><td>-</td><td>Deceased</td><td>NR</td></tr><tr><td>3*</td><td>65</td><td>M</td><td>AEF</td><td>Brain CT</td><td>-</td><td>Sternotomy, Esophageal direct suture, Flap interposition</td><td>NR</td><td>-</td><td>Deceased</td><td>NR</td></tr><tr><td>4</td><td>58</td><td>M</td><td>PEF</td><td>Chest CT</td><td>Yes</td><td>Sternotomy, CPB, Pericardium direct suture, Esophagus direct suture, Flap interposition</td><td>Re Do surgery</td><td>-</td><td>Alive<sup>#</sup></td><td>-</td></tr><tr><td>5*</td><td>65</td><td>M</td><td>AEF</td><td>Chest CT contrast esophagogram</td><td>Yes</td><td>Sternotomy, CPB, LA direct suture, Thoracotomy, Esophagus direct suture, Flap interposition</td><td>NR</td><td>-</td><td>Deceased</td><td>Coma</td></tr><tr><td>6*</td><td>64</td><td>M</td><td>AEF</td><td>TTE</td><td>-</td><td>Thoracotomy, Esophagus direct suture, Flap interposition</td><td>NR</td><td>-</td><td>Deceased</td><td>Coma</td></tr><tr><td>7</td><td>69</td><td>F</td><td>PEF</td><td>Chest CT</td><td>-</td><td>Thoracotomy, partial esophagectomy, Flap interposition</td><td>NR</td><td>Yes<sup>a</sup></td><td>Alive<sup>#</sup></td><td>-</td></tr><tr><td>8*</td><td>49</td><td>M</td><td>AEF</td><td>Brain CT</td><td>-</td><td>Thoracotomy, CPB, LA direct suture, Esophagus direct suture, Flap interposition</td><td>NR</td><td>-</td><td>Deceased</td><td>Cardiopulmonary arrest</td></tr><tr><td>9</td><td>55</td><td>M</td><td>AEF</td><td>EGD</td><td>-</td><td>Clamshell, CPB, LA direct suture, Esophagus direct suture, Flap interposition</td><td>NR</td><td>-</td><td>Alive<sup>#</sup></td><td>-</td></tr><tr><td>10*</td><td>66</td><td>M</td><td>AEF</td><td>Chest CT</td><td>-</td><td>Clamshell, CPB, LA direct suture, Esophagus direct suture, Flap interposition</td><td>NR</td><td>-</td><td>Deceased</td><td>Coma</td></tr><tr><td>11*</td><td>70</td><td>F</td><td>AEF</td><td>EGD</td><td>-</td><td>Clamshell, CPB, LA patch repair, Esophagus direct suture, Flap interposition</td><td>NR</td><td>-</td><td>Alive<sup>#</sup></td><td>-</td></tr><tr><td>12</td><td>44</td><td>M</td><td>AEF</td><td>Chest CT</td><td>-</td><td>Thoracotomy, CPB, LA patch repair, Esophagectomy</td><td>NR</td><td>Yes<sup>b</sup></td><td>Alive<sup>#</sup></td><td>-</td></tr><tr><td>13*</td><td>65</td><td>M</td><td>AEF</td><td>EGD</td><td>Yes</td><td>Thoracotomy, LA patch repair, Esophagectomy</td><td>Re Do surgery</td><td>-</td><td>Deceased</td><td>Multi-organ failure</td></tr><tr><td>14*</td><td>52</td><td>M</td><td>AEF</td><td>Chest CT</td><td>-</td><td>Thoracotomy, LA patch repair, Esophagectomy</td><td>NR</td><td>Yes<sup>b</sup></td><td>Alive<sup>#</sup></td><td>-</td></tr><tr><td>15</td><td>31</td><td>M</td><td>AEF</td><td>Chest CT</td><td>Yes</td><td>Thoracotomy, CPB, LA patch repair, Esophagectomy</td><td>Re Do surgery</td><td>Yes<sup>b</sup></td><td>Alive<sup>#</sup></td><td>-</td></tr><tr><td>16</td><td>64</td><td>M</td><td>AEF</td><td>Chest CT</td><td>-</td><td>Thoracotomy, CPB, LA patch repair, Esophagectomy</td><td>NR</td><td>Yes<sup>b</sup></td><td>Alive<sup>#</sup></td><td>-</td></tr><tr><td>17</td><td>42</td><td>M</td><td>AEF</td><td>Chest CT</td><td>-</td><td>Thoracotomy, CPB, LA patch repair, Esophagectomy</td><td>NR</td><td>-</td><td>Deceased</td><td>Cerebral hemorrhage</td></tr><tr><td>18</td><td>80</td><td>M</td><td>AEF</td><td>Chest CT contrast esophagogram</td><td>Yes</td><td>Thoracotomy, LA repair, Esophagus direct suture, Flap interposition</td><td>Re Do surgery</td><td>-</td><td>Alive<sup>#</sup></td><td>-</td></tr></tbody></table>

EGD: esogastroduodenoscopy; NR: Not reported; *: patient with neurological failure (coma) at initial presentation; #: with sequelae; §: without sequelae; a: restorative surgery with evo-gastric anastomosis; b: restorative surgery with retrosternal colon interposition

## Main Findings

* 5 patients underwent esophageal stenting, 2 as a bridge-to-esophagectomy with 50% of survival, and 3 in association with esophagus and left atrial direct repair with 66% of survival.

* 8 patients underwent a primary direct esophageal repair with flap interposition, without previous stenting, with **25% of survival**.

* 7 patients had an **esophagectomy with 71% of survival**. 5 patients underwent a **restorative surgery** and are **still alive**. 4 patients had a retrosternal colon interposition, whereas one patient had an **eso-gastric anastomosis**.

* **Esophagectomy** tended to be associated with **better survival** (HR 0.163, 95% CI 0.019-1.340; p=0.092).

* **Cardiopulmonary bypass** was used for twelve patients and did not significantly impact survival (HR 1.953, 95% CI 0.392-9.719; p=0.413).

## Limitation and strength

Only 18 patients were included which can be explained by the rare incidence of AEF. Many surgical strategies were assessed with only few patients in each group, decreasing statistical power and limiting statistical analysis.

However, apart from review of literature, our study is the **largest nationwide cohort** on atrio-esophageal fistula to date.

## Conclusion

Surgical management of AEF is challenging. Sepsis at initial presentation is a risk of death.

Esophagectomy appears to offer the highest survival rate and should be considered as a valuable damage control strategy.

<footnote n="1">¹ Department of Thoracic and Endocrine Surgery, Centre Jean Perrin, Clermont-Ferrand, France ; ² Department of Cardiothoracic Surgery, Sorbonne University, La Pitié-Salpêtrière Hospital AP-HP, Paris, France ; ³ Division of Cardiothoracic Surgery and Transplantation, Henri Mondor Hospital, France ; ⁴ Department of Cardiac Surgery, Tours University Hospital, Tours, France ; ⁵ Digestive Surgery and Liver Transplantation Unit, Nice University Hospital, Nice, France ; ⁶ Department of Cardiovascular and Thoracic Surgery, University Hospital, Angers, France ; ⁷ Biostatistics Unit, University Hospital Gabriel Montpied, Clermont-Ferrand, France.</footnote>