Background:

Oesophageal fistula (OF) is a rare but devastating complication following atrial fibrillation (AF) ablation. The data regarding the impact of gender 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 117 patients. Herein we conducted a gender- based analysis of the patients exhibiting OF. 

Results: 

Females represented 47% of the study population, which is a notable finding considering that the female population represent only a minority of the patients receiving AF/AT ablation. They were less likely to have atrioesophageal fistula (90.9% vs. 100%; p=0.021). Oesophageal-pericardial fistula occurred solely in females (7.3% vs. 0%; p=0.046). 

Excepting congestive heart failure, which was significantly less frequent in the female population (7.4% vs. 26.7%; p=0.012), no difference was seen between genders regarding the baseline characteristics and comorbidities including BMI and CHA₂DS₂VASc score. The median hospitalization duration was 5.5 days for women and 3 days for men (p=0.163). No difference was noted in terms of sedation type, energy source, and ablation technique used, as well as in terms of oesophageal temperature probe utilization. Interestingly, significantly less women received proton pump inhibitors (PPI) postprocedural (64.8% vs. 84.7%; p=0.017). The median duration until symptoms onset was 20 days for women and 16.5 days for men (p=0.140), while the median duration until OF diagnosis was 22.5 days and 19.5 days respectively (p=0.217). In terms of OF diagnosis method, significantly more women received echocardiography (36.4% vs. 15%; p=0.010), while there was no difference between the genders regarding the other diagnosis techniques. As postprocedural complications besides OF, significantly more women exhibited stroke (32.7% vs. 14.8%; p=0.040), while there was no significant difference regarding the incidence of septic shock, coma, cardiac arrest, cardiac tamponade, and gastro-intestinal bleeding. Significantly more women than men presented no complications other than OF (9.6% vs. 0%; p=0.026). 

The endoscopic treatment was used more often in the female population (35.8% vs. 17.7%; p=0.034), while a trend towards a higher rate of surgical treatment was seen in the male population (54.8% vs. 39.6%; p=0.134). Moreover, females were less likely to receive a direct surgical treatment, without stenting (28.3% vs. 51.6%; p=0.014). The mortality was 63.6% for women and 67.2% for men (p=0.700), with no difference in terms of major and minor sequelae. 

Conclusion:

Approximatively half of the patients exhibiting postprocedural OF are females. Oesophageal-pericardial fistulas occurred solely in the female population. Women showed a higher rate of endoscopic treatment and a lower rate of direct surgical treatment. No difference was noted between genders in terms of survival, as well as in minor and major sequelae.