Atrial-Esophageal Fistula after Thoracoscopic Maze Surgery: The Real Perspective

“Reply by the Authors of the Original Article”

We would like to comment on the devastating complication following endoscopic ablation reported by Kik et al.[1] In their conclusion, they challenge the “low-risk character” of this procedure. While the occurrence of such a complication in 3 out of 21 patients might have contributed to their messaging, we believe this has not been brought to the right perspective throughout their communication.

A recent meta-analysis of almost 1,200 patients who underwent thoracoscopic ablation revealed not one single report of atrioesophageal fistula.[2] In our combined series of more than 600 thoracoscopic ablation procedures in which the same device was applied we have never encountered this complication either (manuscript to be submitted). In the reported series, after finishing the proctored training that was uneventful with regard of complications, a fistula occurred in almost every fourth patient. Their overall major adverse event rate was even higher. The authors could not provide any rationale how a bipolar radiofrequency device could cause harm to the esophageal surroundings if used correctly and accordingly to the instruction for use of the device. During ablation of the connecting lesion between the left and right pulmonary veins, the ablation device has to be turned toward the posterior wall of the left atrium away from the esophagus. Moreover, the pressure applied by the device toward the posterior atrial wall to ensure good electrode-tissue contact moves the probe even further away from any adjacent anatomical structure. However, if good visualization is not established which is critical for the safe ablation of the connecting lesions and one of the challenges in the early learning curve, unintentional rotation of the ablation tool could potentially heat and damage the esophagus. This might be even worse in case of the presence of a TEE probe inside the esophagus at this level, especially if the probe is switched on transmitting ultrawaves. We completely agree with the authors that this complication has been reported for catheter ablation, in which a unipolar device is always pointed towards the esophagus. However, exactly this should not be the case in this type of procedure.

While it is important to point out potential complications and risk factors of a procedure, it is also the responsibility of the ones reporting to make sure they have successfully completed their learning curve and take use of all the intraoperative support offered, especially if uncommon issues occur, before bringing a standardized and low-risk procedure into discredit. This letter is by no means driven by any disclosed financial relationship to the manufacturer of the used devices but by our convincing that this procedure, if properly trained and performed on a regular base, is an effective and safe treatment option for patients who would otherwise keep exposed to their symptoms and the risk of stroke. which has been confirmed by multiple large series reports.

• References

• 1 Kik C, van Valen R, Mokhles MM, Bekkers JA, Bogers AJ. Atrioesophageal fistula after minimally invasive video-assisted epicardial ablation for lone atrial fibrillation. Thorac Cardiovasc Surg 2016; DOI: 10.1055/s-0036-1592436.
• 2 Van Laar C, Kelder J, Van Putte BP. The totally thoracoscopic maze procedure for the treatment of atrial fibrillation. Interact Cardiovasc Surg 2017; 24 (01) 102-111