Surgery saves lives in patients with oesophageal fistula 

The large, real-world POTTER-AF study showed that a surgical or an endoscopic intervention is a necessity to reduce the risk of death in patients with oesophageal fistula (OF) following catheter ablation for atrial fibrillation (AF). With conservative treatment only, the mortality rate is approximately 90%.

“OFs are a rare but devastating complication of AF,” said Prof. Roland Tilz (University Heart Center Lübeck, Germany) [1]. “Currently, data on the incidence, management, and outcomes of OF is sparse.” Thus, the POTTER-AF study (NCT05273645) aimed to investigate the real-world incidence, management, and outcomes of OF in patients with AF who underwent catheter ablation [1,2].

In total, 214 centres in 35 countries performed 553,729 procedures; 138 cases of OF were detected, resulting in an incidence of 0.025% in the study population. Furthermore, the risk of OF was higher in those undergoing radiofrequency ablation compared with those receiving cryoballoon ablation (0.038% vs 0.0015%; P<0.001). Prof. Tilz mentioned that the median time to symptom onset was 18 days and that the median time to OF diagnosis was 21 days. “Fever, chest pain, neurological symptoms, and odynophagia were the most common symptoms,” he added. The most common delayed complication was severe sepsis, occurring in more than 50% of the patients with OF. Additionally, approximately 25% of the patients suffered from a cerebrovascular event, and 1 out of 5 patients had a cardiac arrest.

“The outcomes for OF are abysmal, with a mortality rate of 65.8%,” emphasised Prof. Tilz. “Only 15.4% of the patients survive without sequela.” Importantly, the death rate is much higher in patients who were treated conservatively (90%) than in patients who underwent endoscopic treatment (56%) or surgical treatment (52%). Finally, the use of an oesophageal temperature probe and the type of anaesthesia (i.e. conscious sedation) were associated with better survival outcomes.

“Thus, surgical or endoscopic intervention is mandatory to improve the survival outcomes in patients with OF,” concluded Prof. Tilz.

1. 
   
   1. Tilz RR, et al. Prognosis following oesophageal fistula formation in patients undergoing catheter ablation for AF: The POTTER AF Study. Late-Breaking Science Day 1, EHRA 2023, 16–18 April, Barcelona, Spain.
   2. Tilz RR, et al. Eur Heart J. 2023;Apr 16.DOI: 10.1093/eurheartj/ehad250.

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Posted on 3 May, 2023