Restricted accessResearch articleFirst published online 2025
Atrioesophageal Fistulae After Ablation for Atrial Fibrillation (AF): A Timely Approach to the Early Identification and Management of a Critical Complication
The occurrence of atrioesophageal fistulae (AEF) after ablative therapy for atrial fibrillation (AF) represents a rare yet frequently fatal complication, with mortality approaching 100% without prompt surgical intervention. Delayed intervention has been associated with devastating outcomes, underscoring the importance of early identification of this disease process, as well as rapid clinical decision-making and management. Key concepts in endoscopic management include avoidance of air insufflation during endoscopy and refraining from use of stents. The present article provides a comprehensive review of current strategies for timely diagnosis and appropriate, multidisciplinary management to mitigate the morbidity and mortality associated with this life-threatening process.
HoytHBhonsaleAChilukuriK, et al. Complications arising from catheter ablation of atrial fibrillation: temporal trends and predictors. Heart Rhythm. 2011;8(12):1869-1874. doi:10.1016/j.hrthm.2011.07.025
2.
BenaliKKhairyPHammacheN, et al. Procedure-related complications of catheter ablation for atrial fibrillation. J Am Coll Cardiol. 2023;81(21):2089-2099. doi:10.1016/j.jacc.2023.03.418
3.
GuptaAPereraTGanesanA, et al. Complications of catheter ablation of atrial fibrillation. Circul Arrhyth Electrophysiol. 2013;6(6):1082-1088. doi:10.1161/CIRCEP.113.000768
4.
KhanMRashidMUZafarHUllahWKhanAH.A rare complication of cardiac ablation: atrial-esophageal fistula presenting as odynophagia. Cureus. 2020;12(2):e6871. doi:10.7759/cureus.6871
5.
HeFZhangWMXuBJHuangGPChenHD.Atrioesophageal fistula after atrial fibrillation catheter ablation: a case report. Medicine (Baltimore). 2021;100(2):e24226. doi:10.1097/md.0000000000024226
6.
BarbhaiyaCRKumarSGuoY, et al. Global survey of esophageal injury in atrial fibrillation ablation: characteristics and outcomes of esophageal perforation and fistula. JACC Clin Electrophysiol. 2016;2(2):143-150. doi:10.1016/j.jacep.2015.10.013
KapurSBarbhaiyaCDenekeTMichaudGF.Esophageal injury and atrioesophageal fistula caused by ablation for atrial fibrillation. Circulation. 2017;136(13):1247-1255. doi:10.1161/CIRCULATIONAHA.117.025827
9.
LeungLHayatJGallagherM.Oesophageal Protection During Catheter Ablation for AF: A Simple Solution to a Longstanding Problem?Routledge; 2020.
10.
KikCBogersAJ.Maze procedures for atrial fibrillation, from history to practice. Cardiol Res. 2011;2(5):201-207. doi:10.4021/cr79w
11.
HaïssaguerreMJaïsPShahDC, et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med. 1998;339(10):659-666. doi:10.1056/NEJM199809033391003
12.
McCarthyPMCoxJLKislitsinaON, et al. Surgery and catheter ablation for atrial fibrillation: history, current practice, and future directions. J Clin Med. 2021;11(1):10210. doi:10.3390/jcm11010210
13.
PandaNCCheungJW.Complications from catheter ablation of atrial fibrillation: impact of current and emerging ablation technologies. Curr Treat Options Cardiovasc Med. 2014;16(10):344. doi:10.1007/s11936-014-0344-z
14.
RankinJSLernerDJBraid-ForbesMJMcCreaMMBadhwarV.Surgical ablation of atrial fibrillation concomitant to coronary-artery bypass grafting provides cost-effective mortality reduction. J Thorac Cardiovasc Surg. 2020;160(3):675-686.e13. doi:10.1016/j.jtcvs.2019.07.131
15.
GillinovAMPetterssonGRiceTW.Esophageal injury during radiofrequency ablation for atrial fibrillation. J Thorac Cardiovasc Surg. 2001;122(6):1239-1240. doi:10.1067/mtc.2001.118041
16.
RomeroJAvendanoRGrushkoM, et al. Oesophageal injury during AF ablation: techniques for prevention. Arrhythm Electrophysiol Rev. 2018;7(1):24-31. doi:10.15420/aer.2017.46.2
17.
LeungLWMAkhtarZSheppardMNLouis-AugusteJHayatJGallagherMM. Preventing esophageal complications from atrial fibrillation ablation: a review. Heart Rhythm O2. 2021;2(6Part A):651-664. doi:10.1016/j.hroo.2021.09.004
18.
HanHCHaFJSandersP, et al. Atrioesophageal fistula: clinical presentation, procedural characteristics, diagnostic investigations, and treatment outcomes. Circ Arrhythm Electrophysiol. 2017;10(11):5579. doi:10.1161/circep.117.005579
19.
SmithGAKleimanAM.A rare iatrogenic atrial-esophageal fistula and anesthetic considerations for primary surgical repair. J Cardiothorac Vasc Anesth. 2017;31(6):2156-2160. doi:10.1053/j.jvca.2017.04.016
20.
BodziockGMNortonCAMontgomeryJA.Prevention and treatment of atrioesophageal fistula related to catheter ablation for atrial fibrillation. J Innov Card Rhythm Manag. 2019;10(5):3634-3640. doi:10.19102/icrm.2019.100505
21.
NairKKDanonAValaparambilAKoruthJSSinghSM.Atrioesophageal fistula: a review. J Atr Fibrillation. 2015;8(3):1331. doi:10.4022/jafib.1331
22.
HartmanARGlassmanLKatzSChinitzLRossW.Surgical repair of a left atrial-esophageal fistula after radiofrequency catheter ablation for atrial fibrillation. Ann Thorac Surg. 2012;94(4):e91-e93. doi:10.1016/j.athoracsur.2012.04.052
23.
VelottaJBVasquezCRBolmanRMDasilvaMC.Left atrial-esophageal fistula repair after radiofrequency catheter ablation for atrial fibrillation. Thorac Cardiovasc Surg Rep. 2013;2(1):13-15. doi:10.1055/s-0033-1358779
24.
DudaABeersKMitiekM.Surgical management of atrial-esophageal fistula as a complication of atrial fibrillation ablation. J Surg Case Rep. 2022;(1):497
25.
RiveraGADavidIBAnandRG.Successful atrioesophageal fistula repair after atrial fibrillation ablation. J Am Coll Cardiol. 2013;61(11):1204. doi:10.1016/j.jacc.2012.09.068
26.
St. JulienJPutnamJBNesbittJCLambrightESPetracekMRGroganEL.Successful treatment of atrioesophageal fistula by cervical esophageal ligation and decompression. Ann Thorac Surg. 2011;91(6):e85-e86. doi:10.1016/j.athoracsur.2011.01.039
27.
SinghSMd’AvilaASinghSK, et al. Clinical outcomes after repair of left atrial esophageal fistulas occurring after atrial fibrillation ablation procedures. Heart Rhythm. 2013;10(11):1591-1597. doi:10.1016/j.hrthm.2013.08.012
28.
ShimamuraJMoussaFTarolaC, et al. Surgical repair of atrial-esophageal fistula following catheter ablation. Ann Thorac Surg. 2022;113(4):e275-e278. doi:10.1016/j.athoracsur.2021.07.004
29.
ChavezPMesserliFHCasso DominguezA, et al. Atrioesophageal fistula following ablation procedures for atrial fibrillation: systematic review of case reports. Open Heart. 2015;2(1):e000257. doi:10.1136/openhrt-2015-000257
30.
ZhanYXuZ.Massive hemorrhage from an aortoesophageal fistula caused by esophageal stent implantation: a case report and literature review. Medicine (Baltimore). 2019;98(51):e18303. doi:10.1097/md.0000000000018303
31.
YousufTKeshmiriHBulwaZ, et al. Management of atrio-esophageal fistula following left atrial ablation. Cardiol Res. 2016;7(1):36-45. doi:10.14740/cr454e
32.
ZellerhoffSLenzeFSchulzREckardtL.Fatal course of esophageal stenting of an atrioesophageal fistula after atrial fibrillation ablation. Heart Rhythm. 2011;8(4):624-626. doi:10.1016/j.hrthm.2010.10.041
33.
MohantySSantangeliPMohantyP, et al. Outcomes of atrioesophageal fistula following catheter ablation of atrial fibrillation treated with surgical repair versus esophageal stenting. J Cardiovasc Electrophysiol. 2014;25(6):579-584. doi:10.1111/jce.12386
34.
JehaludiAHeistEKGiveansMRAnandR.Retrospective review of 65 atrioesophageal fistulas post atrial fibrillation ablation. Indian Pacing Electrophysiol J. 2018;18(3):100-107. doi:10.1016/j.ipej.2018.02.002
35.
DupautetLLebretonGSaiydounG, et al. Surgical management of atrioesophageal fistula after catheter ablation of atrial fibrillation: a French nationwide study. JTCVS Open. 2024;22:476-484. doi:10.1016/j.xjon.2024.09.010
36.
HalmUGasparTZachäusM, et al. Thermal esophageal lesions after radiofrequency catheter ablation of left atrial arrhythmias. Am Coll Gastroenterol. 2010;105(3):551-556. doi:10.1038/ajg.2009.625
37.
KiuchiKOkajimaKShimaneA, et al. Impact of esophageal temperature monitoring guided atrial fibrillation ablation on preventing asymptomatic excessive transmural injury. J Arrhythm. 2016;32(1):36-41. doi:10.1016/j.joa.2015.07.003
38.
Di BiaseLSaenzLCBurkhardtDJ, et al. Esophageal capsule endoscopy after radiofrequency catheter ablation for atrial fibrillation: documented higher risk of luminal esophageal damage with general anesthesia as compared with conscious sedation. Circ Arrhythm Electrophysiol. 2009;2(2):108-112. doi:10.1161/circep.108.815266
39.
BhardwajRNaniwadekarAWhangW, et al. Esophageal deviation during atrial fibrillation ablation: clinical experience with a dedicated esophageal balloon retractor. JACC Clin Electrophysiol. 2018;4(8):1020-1030. doi:10.1016/j.jacep.2018.04.001
40.
LeungLWMAkhtarZElbatranAI, et al. Effect of esophageal cooling on ablation lesion formation in the left atrium: insights from Ablation Index data in the IMPACT trial and clinical outcomes. J Cardiovasc Electrophysiol. 2022;33(12):2546-2557. doi:10.1111/jce.15717
