Atrial Esophageal Fistulas: A Case Series Demonstrating Three Distinct Operative Approaches with Favorable Outcomes.

Background: Atrial esophageal fistula (AEF) is a rare complication of atrial ablation procedures. Because of the low incidence and associated morbidity and mortality, there is no consensus on optimal treatment. We present our experience with 4 patients, each with a different management strategy. Methods: Retrospective chart review of 4 patients treated for AEF at a single tertiary care center was performed. Patients were treated between March 2020 and April 2024. Results: Three patients underwent surgical repair of the AEF and 1 underwent a combination of endoscopic and percutaneous approaches. Two of the surgical patients underwent right thoracotomy, while the third was approached via median sternotomy on cardiopulmonary bypass followed by a right thoracotomy. The 3 patients who underwent surgical repair are alive and tolerating oral intake. The patient who underwent endoscopic/percutaneous AEF repair had a considerably higher surgical risk at baseline. The patient recovered from the initial interventions and was discharged home but represented with AEF progression and subsequently expired secondary to neurologic sequalae. Conclusions: For AEF, open surgical management with or without the use of cardiopulmonary bypass has historically been the first-line treatment. Although successful management of AEF with endoscopic treatment has been documented in the literature, only surgical repair was successful in this case series. This series suggests that surgical management should be pursued for all patients except those with highly prohibitive surgical risk.