Endoscopic versus surgical treatment for the management of oesophageal fistula after atrial fibrillation ablation - a subanalysis of the worldwide POTTER-AF study
Authors: Popescu S S , Schmidt V , Heeger C H , Puererfellner H , Vogler J , Steven D , Veltmann C , Keelani A , Kuck K H , Merino J L , Tilz R R 
Published: May 2024

Abstract

Background
Oesophageal fistula (OF) is considered the most dreadful complication of atrial fibrillation (AF) catheter ablation. The endoscopic and surgical treatment of OF has been proposed to improve the prognosis of these patients, but the data on the individual impact of each treatment technique are scarce.

Methods
The POTTER-AF study is a worldwide, multi-centre registry conducted under the auspices of the Working Group of Cardiac Electrophysiology of the German Cardiac Society (AGEP, DGK) which evaluated the incidence, management, and outcome of post-procedural OF following catheter ablation of AF [1]. A total of 553 729 patients underwent ablation procedures for AF or atrial tachycardia (AT) in 214 electrophysiological centres from 35 countries between 1996 and 2022. Of them, 138 (0.025%) patients experienced postprocedural OF and data regarding the therapeutical approach were available in 116 patients. Of them, 78 underwent surgical or interventional treatment. Herein we conducted a therapy- based analysis of the patients exhibiting OF.

Purpose
To assess the impact of each therapeutical approach on the prognosis of patients developing OF after AF or AT ablation.

Results
A total of 23 (29.5%) patients were treated using endoscopic interventions only (Endoscopy group), while 55 (70.5%) patients underwent surgical procedures (Surgery group). Of the latter, 8 (14.5%) underwent previous endoscopic treatment. The endoscopic therapy consisted of oesophageal stenting (n = 28), clipping (n = 2), or vacuum-assisted-closure therapy (n = 1).
There was no difference between the Endoscopy and Surgery groups regarding the demographic characteristics and comorbidities. The energy sources used were also similar between the groups (Figure 1). There was a trend towards a higher use of an oesophageal thermal probe in the Endoscopy group (43.5% vs. 21.8%; p=0.096). The duration until symptoms onset was 10 (5.5; 18.5) days in the Endoscopy group and 18.0 (10.0; 22.0) days in the Surgery group (p=0.081), while the time to OF diagnosis was 18.0 (10.0; 26.0) days and 20.0 (15.0; 29.25) days respectively (p=0.10; Figure 2). The symptoms at presentation were similar between the two groups. Endoscopy was the diagnostic method in 45.5% of the patients in the Endoscopy group and in 16.7% in the Surgery group (p=0.017). The subsequent complications of the OF were also similar between groups. The mortality was 56.5% in the Endoscopy group and 51.9% in the Surgery group (p=0.805), while minor sequalae occurred in 8.7% patients in the former group and 16.7% in the latter (p=0.490) and major sequalae in 4.3% and 16.7% respectively (p=0.266).

Conclusion
There was no clinical or paraclinical parameter associated with the choice of the therapeutical approach. Patients diagnosed by means of endoscopy were more likely to undergo exclusively endoscopic interventions. The mortality, incidence of minor and major sequalae were similar between the groups.