Puzzling Challenge of Atrioesophageal Fistula
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SeeArticle by Han et al
Atrial fibrillation (AF) is the most common cardiac dysrhythmia, with a lifetime risk of about 1:4 by 80 years of age.1 The current guidelines recommend catheter ablation in patients with symptomatic AF resistant to or intolerant of antiarrhythmic medications and in selected cases even before a trial of antiarrhythmic medications.2 Shortly, the indications are very likely to extend to some congestive heart failure patients too. Not surprisingly, the utilization of catheter ablation as a treatment modality for AF patients has exploded and its annual growth rate exceeded that of many other cardiovascular procedures.3 AF ablation currently accounts for about one third of the caseload in electrophysiology laboratories in the Western world.4 Yet, the risks involved with AF ablation remain substantial. The risk of major complications is reported at 4.5%,5 whereas fatal or potentially fatal complications are occurring in 1 of 1000 patients.6
The reported risk of atrioesophageal fistula (AEF) varies between different cohorts at around 0.1% and 0.2%,7,8 with a devastating subsequent mortality rate reported earlier at above 80%.9 In a recent Canadian survey accounting for 7016 AF ablations, the rate of proven AEF was 0.07% among Canadian centers.10 Likely, the rate of AEF reported in the literature does not reflect the magnitude of this serious complication in current practice given the under/miss diagnosis and the death cases of unknown cause that could be attributable to AEF. It is also because of the fact that it is a delayed complication …