Impact of gender on the management and prognosis of oesophageal fistula after atrial fibrillation ablation - a subanalysis of the worldwide POTTER-AF study
Authors: Popescu S S , Heeger C H , Schmidt V , Puererfellner H , Vogler J , Steven D , Keelani A , Kuck K H , Merino J L , Tilz R R 
Published: May 2024

Abstract

Background
Oesophageal fistula (OF) is a rare but devastating complication following atrial fibrillation (AF) ablation. The data regarding the impact of gender on the management and prognosis of OF 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. 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 gender, management and prognosis were available in 117 patients. Herein we conducted a gender- based analysis of the patients exhibiting OF.

Purpose
To evaluate the impact of gender on the management and prognosis of OF.

Results
Females represented 47% of the study population, which is a notable finding considering that the female population represents only a minority of the patients receiving AF/AT ablation. They were less likely to have atrioesophageal fistula (90.9% vs. 100%; p=0.021). Oesophageal-pericardial fistula occurred solely in females (7.3% vs. 0%; p=0.046).
Congestive heart failure was significantly less frequent in the female population (7.4% vs. 26.7%; p=0.012). No other difference was seen between genders regarding the baseline characteristics and comorbidities (Table1). The energy source, ablation technique and utilization of oesophageal temperature probes were similar for males and females. Significantly less women received proton pump inhibitors (PPI) postprocedural (64.8% vs. 84.7%; p=0.017). The median duration until onset of symptoms was 20 days for women and 16.5 days for men (p=0.14), while the median duration until OF diagnosis was 22.5 days and 19.5 days respectively (p=0.217). Significantly more women underwent echocardiography (36.4% vs. 15%; p=0.01) as diagnostic method. More women exhibited stroke (32.7% vs. 14.8%; p=0.040), while there was no significant difference regarding the incidence of septic shock, coma, cardiac arrest, cardiac tamponade, and gastro-intestinal bleeding. Significantly more women than men presented no complications other than OF (9.6% vs. 0%; p=0.026).
The females were more likely to undergo endoscopic treatment (35.8% vs. 17.7%; p=0.034), but less likely to undergo direct surgical treatment, without stenting (28.3% vs. 51.6%; p=0.014) (Figure1). The mortality was 63.6% for women and 67.2% for men (p=0.70), with no difference in terms of major and minor sequelae.

Conclusion
Approximatively half of the patients exhibiting postprocedural OF are females. Women showed a higher rate of endoscopic treatment and a lower rate of direct surgical treatment. The survival, as well as the incidence of minor and major sequelae were similar between genders.