Scope of the Problem – Meta-Analysis
The first description of AEF with radiofrequency ablation (RFA) of AF
was in 20042, with subsequent publications reporting
upon the variable presentation, delayed recognition, and high mortality
owing to air embolism, sepsis, endocarditis and gastroesophageal
exsanguination3-10. Although this complication occurs
at a low frequency of 0.1-0.2%11,12 considering the
large number of AF ablations being performed worldwide
(~180,000 annually), this would translate to AEF
occurrence of 180-360 patients annually.
In contrast to the low incidence of life-threatening AEF, the incidence
of esophageal injury and ulcerations, believed to be precursors to AEF,
has been reported as high as 47% of patients who undergo
ablation9. The appendix presents a meta-analysis of 42
studies (and the reference list) that assess the incidence of
ablation-related esophageal injury confirmed by endoscopy. The total
number of patients included is 5206 and the occurrence of endoscopy
detected esophageal lesions was 758 patients, thus a rate of 14.5%. It
is important to note that esophageal injury has been reported with use
of the full spectrum of ablation methodologies: percutaneous RFA using
8mm and irrigated-tip single electrode, cryo-balloon energy,
high-intensity focused ultrasound ablation, irrigated circular RFA,
duty-cycled phased RFA, hot balloon ablation, minimally-invasive
surgical ablation and robotic navigation3-12.
Furthermore, with the introduction of contact force catheters, the
incidence of AEF has been reported to be increasing13.