Overestimation and Underweighting of Rare Events: The Challenge of Preventing Atrial-Esophageal Fistula After Ablation

摘要

Atrial-esophageal fistula (AEF) and other esophageal injury disorders after catheter ablation for atrial fibrillation (AF) remain a significant source of post-procedural morbidity and mortality. AEF is rare, with a recent estimated incidence of 0.016% (1), but moribund without early recognition, patient stabilization, and corrective intervention (2). Despite the rarity of AEF, poor prognosis has prompted the need to define procedural approaches to lower the risk even further.AEF has been reported with multiple ablative energies, including cryothermal, radiofrequency, and high-intensity focused ultrasound, and across diverse approaches of surgical, percutaneous, and robotic navigation (3,4). Although commonly used, esophageal temperature monitoring probes have shown no benefit; some studies have shown increased risk of esophageal injury with their use. Outcomes reflect the poor sensitivity these monitors have, coupled with inherent latent detection of esophageal heating (5).