Background:

Oesophageal fistula (OF) is a rare but devastating complication following atrial fibrillation (AF) ablation. The data regarding the impact of age on the management and prognosis of OF are scarce. 

Methods:  

The POTTER-AF study is a worldwide, multi-centre registry conducted under the auspices of the Working Group of Cardiac Electrophysiology of the German Cardiac Society (AGEP, DGK) which evaluated the incidence, management, and outcome of post-procedural OF following catheter ablation of AF.  A total of 553 279 patients underwent ablation procedures for AF or atrial tachycardia (AT) in 214 electrophysiological centres from 35 countries between 1996 and 2022. Of them, 138 (0.025%) patients experienced postprocedural OF and data regarding the management and prognosis were available in 113 patients. The median age was 63 years. 

Results:

A total of 54 (47.8%) patients experiencing OF were younger than 63 years old (Group 1), while 59 (52.2%) patients were at least 63 years old (Group 2). No difference was noted between the groups regarding the incidence of atrioesophageal fistula, oesophageal perforation, and oesophageal-pericardial fistula. Almost half of the patients in each group were females (44.4% vs. 48.3%; p=0.813). As expected, a CHA₂DS₂-VASc score higher than 3 was more frequent in the older population (61% vs. 17.3%; p<0.001). Regarding the comorbidities, the patients in Group 2 were more likely to suffer from coronary artery disease (25% vs. 9.8%; p=0.046) and hypertension (72.9% vs. 42.6%; p=0.001). The two populations were similar in terms of sedation type, energy source and ablation techniques used, as well as in terms of oesophageal temperature probe utilization. Interestingly, the older population had a shorter median time to symptoms onset (15 (6, 21) vs. 21 (10, 25.3) days; p=0.031). Fever, chest pain and neurological signs as first manifestations of OF showed similar incidences between the groups.  When analysing the diagnostic method, the patients from Group 2 were less likely to receive a cranial computed tomography (cCT) or cranial magnetic resonance imaging (cMRI) (25.9% vs. 45.3%; p=0.046). In terms of other postprocedural complications besides OF, the incidence of stroke, septic shock, coma, cardiac arrest, cardiac tamponade, and gastrointestinal bleeding were similar in both groups. The older population was more likely to receive a direct endoscopic treatment, without surgery (27.6% vs. 11.3%; p=0.035), while there was no difference regarding the rate of surgical treatment. The conservative treatment was used in similar proportions (37.7% in Group 1 vs. 29.3% in Group 2; p=0.421). A clear trend towards a higher mortality was noted in the older population (72.9% vs. 56.6%; p=0.078). The incidence of major and minor sequelae was similar for both groups. 

Conclusion:
The median age of the OF population was 63. The older population had a shorter time to symptoms onset, was less likely to receive cCT/cMRI as diagnosis method and more likely to be treated by endoscopic treatment only. The patients older than 63 years showed a trend towards a higher mortality.