Atrioesophageal Fistula after Minimally Invasive Video-Assisted Epicardial Ablation Reported by Kik
19 October 2016
07 November 2016
09 January 2017 (online)
I would like to share my comments regarding the Short Communication report “Atrioesophageal Fistula after Minimally Invasive Video-Assisted Epicardial Ablation for Lone Atrial Fibrillation” by Kik et al published in the recent Thoracic and Cardiovascular Surgeon (DOI: http://dx.doi.org/10.1055/s-0036-1592436; ISSN: 0171–6425). The authors report on three fistulae following the thoracoscopic bilateral epicardial ablation of atrial fibrillation (AF) using the AtriCure system.
We have been involved in the minimally invasive AF ablation procedures for more than 12 years and performed few hundreds of them using practically all devices that have been introduced in the market during that time, and in the past 6 years we have been performing regularly the depicted kind of procedure as a teaching center. The occurrence of three atrio-esophageal fistulas (AEFs) in one center within relatively short time frame should raise concern, especially in a procedure that is very well validated and standardized over the past decade. Unfortunately, I am not aware of the team's experience. From the technical point of view, knowing the technical features of the system it is difficult to understand the surgical mechanism behind it. The system is based on the bipolar/transpolar energy delivery with the current transmission only between the electrodes located within the device (no zero electrode), and the active side of the device is clearly indicated by its construction. The procedure is thoracoscopically easily controlled and the only way of injuring the esophagus would be by facing the active side toward it, which should not be treated as the system or procedure failure. The applicator is touched epicardially under vision to the atrium and pushed gently against it away from adjacent tissues under electronic generator unit control showing the current adherence. Every ablating system has naturally its strong and weak points, but in terms of AEF creation the system construction belongs to the safest. As mentioned earlier, the procedure is very well evaluated and standardized over the past decade, with few thousands of cases published from all over the world, including prospective controlled randomized trials, meta-analyses, and also personal communication, revealing no complication such as this.  
- 1 Boersma LV, Castella M, van Boven W. , et al. Atrial fibrillation catheter ablation versus surgical ablation treatment (FAST): a 2-center randomized clinical trial. Circulation 2012; 125 (01) 23-30
- 2 Phan K, Phan S, Thiagalingam A, Medi C, Yan TD. Thoracoscopic surgical ablation versus catheter ablation for atrial fibrillation. Eur J Cardiothorac Surg 2016; 49 (04) 1044-1051
- 3 van Laar C, Kelder J, van Putte BP. The totally thoracoscopic maze procedure for the treatment of atrial fibrillation. Interact Cardiovasc Thorac Surg 2016; DOI: 10.1093/icvts/ivw311.