Surgical Treatment of Atrioesophageal Fistula: A Systematic Review

BACKGROUND: Atrioesophageal fistula is a rare and morbid complication of ablation therapy for atrial fibrillation. Surgery provides increased survival; however, which surgical approach provides the best outcome is unclear.

METHODS: We performed a retrospective analysis of cases in the literature and at our institution. We characterized patients by presenting symptoms, diagnostic method, surgical therapy with different approaches, and survival.

RESULTS: In total, 219 patients were found, with 216 patients identified from 122 papers in the literature and 3 patients from our institutional database (2000-2022). The most common presenting symptoms included fever/chill (71.8%) and neurologic deficiency (62.9%). The overall survival for this cohort was 47%. Patients who had an operation had significantly improved survival compared with those who did not have an operation (71.9.3% vs 11%, P < .001). Patients who survived after surgical intervention typically underwent right thoracotomy (45.1%), patch repair of the left atrium (61.1%), and primary repair of the esophagus (68.3%) on cardiopulmonary bypass (84.8%) with a flap between the 2 organs (84.6%). Patients who had cardiopulmonary bypass had increased survival (39 of 45 [86.7%]) compared with those who did not have cardiopulmonary bypass (7 of 17 [41.2%], P < .001).

CONCLUSIONS: Patients with atrioesophageal fistula should undergo surgical intervention. A patch repair of the left atrium and primary repair of the esophagus with a flap between the organs during cardiopulmonary bypass is the most common successful repair. Cardiopulmonary bypass may allow better débridement and repair of the left atrium, which may provide a survival advantage in the treatment of this rare disease.