Reply by the Authors of the Original Article

“Atrial-Esophageal Fistula after Thoracoscopic Maze Surgery: The Real Perspective”

We have read the letter to the editor concerning our article about atrioesophageal fistula after thoracoscopic maze surgery with interest.

In this letter, the occurrence of this catastrophic complication is attributed to our learning curve, and the authors comment on the very rare character of this complication and the absence of this complication in their large series. Some comments from our side are as follows.

In our short communication, we describe three cases.[1] The last case was from another hospital. The reason for referral to our hospital was our unfortunate “expertise” with this complication. We were somewhat surprised by the apparent need of one of the authors to disclose information about complications in our center that are not relevant to the key message of this communication and are not mentioned in our report.

We fully agree that the occurrence of an atrioesophageal fistula after thoracoscopic maze surgery is rare. However, it does happen and early recognition is vital. This is especially important because of the relative long time frame between initial surgery and occurrence of the complication (6–8 weeks).

The complication is well known in the cardiology world, as we had discussed in the communication. The argument of the authors that the relative inexperience of our center can play a role is not relevant for our message. Even more, this procedure is introduced in more centers every day. With this fact, the number of inexperienced operators is growing, potentially leading to a higher chance of occurrence of this complication.

In this light, we advocate that our short communication is seen as a message of caution. Yes, this procedure is the most successful way of treating lone atrial fibrillation. And yes, in experienced hands it is a safe procedure. However, complications do occur and will continue to occur, making transparency even more vital. The response of two surgeons, who have a financial relationship with AtriCure, is, of course, welcome. It would, however, have been more constructive if these colleagues and AtriCure would help make this very rare complication well known, giving patients with this complication the best possible chance for survival and quality of life. Cooperation instead of downsizing of the problem is the correct way to go toward truly safe thoracoscopic maze surgery.

Therefore, we stand by our conclusion. The presumed safety of this procedure can be debated and timely recognition of the complication is vital.

• Reference

• 1 Kik C, van Valen R, Mokhles MM, Bekkers JA, Bogers AJ. Atrioesophageal fistula after minimally invasive video-assisted epicardial ablation for lone atrial fibrillation. Thorac Cardiovasc Surg 2016; DOI: 10.1055/s-0036-1592436.