Be aware and hit hard and early: oesophageal lesions after atrial fibrillation ablation

This commentary refers to ‘A worldwide survey on incidence, management and prognosis of oesophageal fistula formation following atrial fibrillation catheter ablation: The POTTER-AF study’, by R. R. Tilz et al., https://doi.org/10.1093/eurheartj/ehad250 and the discussion piece ‘Early identification of esophageal lesions after atrial fibrillation ablation to prevent atrio-oesophageal fistula’, by M. Scanavacca et al., https://doi.org/10.1093/eurheartj/ehad689. We thank Scanavacca et al. for the opportunity of discussing the important role of iatrogenic oesophageal lesions and their early detection after atrial fibrillation (AF) catheter ablation.1 We acknowledge the important point raised by the authors concerning the importance of early detection of this rare but devastating complication. Since the first description of an oesophageal fistula (OF) after AF catheter ablation, only limited data based on case reports, case series, and registries have been reported.2,3 In the POTTER-AF study we therefore aimed to evaluate the incidence, management, and outcome of OF in a large dataset by performing a worldwide data collection with a total of 553 279 patients, 138 patients with a reported OF and an overall incidence of 0.025%.4 It is essential to state that rate of OF is much higher for patients treated by radiofrequency (0.038%) compared to the cryoballoon (0.0015%, P < .0001),4 and might be further reduced with novel technologies like high-power short-duration and pulse field ablation.5 Although POTTER-AF represents the largest dataset up to date there are some limitations and we agree with Scanavacca et al. that no Latin American centres shared data and no systematic post-procedural detection routine has been implemented. Therefore, the real rate of post-procedural OF might be higher than reported. This limitation might be driven by its relatively late occurrence and its typical non-cardiac symptoms. Furthermore, these observations are responsible for the late detection and late treatment of OF and their high mortality of 65.8%.4 We congratulate the authors for their important work and for implementing an OF prevention strategy in their programme. By systematically utilizing oesophageal temperature probes, routine active screening via endoscopy, and clinical evaluation of all patients with AF catheter ablation after 30th days the rate of OF was relatively low and, most importantly, the rate of death and sequelae was zero.1 This systematic post-procedural surveillance led to an excellent outcome. However, the data must be interpreted with caution as the incidence of OF is very low. Preventive endoscopy might result in complications and the concept that early identification of oesophageal lesions may prevent OF needs to be proven in a randomized trial. The results of the study by Scanavacca et al. are in line with our study. The patients with the lowest mortality in POTTER-AF were patients with an early detection of an OF, because those patients received an early treatment via endoscopy or oesophageal surgery with a lower mortality of 56.5% (endoscopy) and 51.9% (surgery) compared to patients with conservative treatment (mortality 89.5%).4 Therefore, we conclude that it is essential to detect this complication early in order to plan a rapid treatment while patients with late detection more often receive a conservative treatment which is devastating in most cases. Besides the above-mentioned post-procedural screening strategies, it is essential to create awareness of this iatrogenic complication in patients, cardiologists, and referring physicians to improve the outcome of this fatal complication. If you wait or do not do anything our patients are dead. Be aware and hit hard and early. Nothing to declare.