University of Athens, Second Cardiology Department, Attikon University Hospital, Athens, Greece.
Curr Opin Cardiol. 2011 Jan;26(1):1-5. doi: 10.1097/HCO.0b013e328341387d.
The formation of atrial-esophageal fistula after catheter ablation for atrial fibrillation is a rare but devastating complication with high mortality. Prevention is of utmost importance. We review the usefulness of currently available preventive measures.
Recent studies using endoscopy after atrial fibrillation ablation show the development of esophageal ulcerations in 14-17% of the patients. Risk factors for the occurrence of esophageal ulcerations seem to be a high esophageal luminal temperature during ablation, increased power during energy application at the posterior left-atrial wall, a short left atrium-to-esophagus distance, the use of nasogastric tubes and general anesthesia. The main available tools for prevention of atrial-esophageal fistula include: 1) Assessment of the esophagus position in the preprocedural CT/MRI scan. Its usefulness is limited by the potential of the esophagus to move. 2) Tagging of the esophagus and real-time visualization of its course during the procedure. This can be achieved by introduction of a catheter into the esophagus and visualization in the three-dimensional electroanatomical system, by intracardiac ultrasound or by fluoroscopy. 3) Continuous monitoring of the esophageal luminal temperature during ablation with special temperature sensors. 4) Reduction of power during energy application at the posterior left-atrial wall in close proximity to the esophagus. Despite application of preventive measures, cases of atrial-esophageal fistulas have been reported.
Several measures for prevention of atrial-esophageal fistula formation are available nowadays. Although these measures cannot completely eliminate the risk of fistula, it appears prudent to apply a combination of them during atrial fibrillation ablation.
房颤导管消融术后并发心房-食管瘘是一种罕见但具有高死亡率的破坏性并发症。预防是重中之重。我们回顾了目前可用的预防措施的效用。
最近在房颤消融后使用内镜的研究表明，14-17%的患者出现食管溃疡。食管溃疡发生的危险因素似乎是消融过程中食管腔内温度高、左心房后壁能量应用时功率增加、左心房到食管的距离短、使用鼻胃管和全身麻醉。预防心房-食管瘘的主要方法包括：1）在术前 CT/MRI 扫描中评估食管位置。其局限性在于食管可能移动。2）标记食管并在手术过程中实时显示其路径。这可以通过将导管插入食管并在三维电解剖系统中可视化、通过心内超声或透视来实现。3）在消融过程中使用特殊温度传感器连续监测食管腔内温度。4）在靠近食管的左心房后壁能量应用时降低功率。尽管采取了预防措施，但仍有报道称发生了心房-食管瘘。
目前有几种预防心房-食管瘘形成的措施。尽管这些措施不能完全消除瘘的风险，但在房颤消融过程中联合应用这些措施似乎是明智的。
