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.