Reply by the Authors of the Original Article (2)

With interest we read the Letter-to-the-Editor by Suwalski regarding our short communication in the Thoracic and Cardiovascular Surgeon and would like to take the opportunity to response to some of the issues raised.

First of all, we would like to refer to our article and our response to the letter on this subject by van Putte et al.

Once again, not all three patients had their TTMAZE surgery in our center. This is clearly described in our short communication. Second, our center has a proven track record, extending over 15 years, in performing surgery for lone atrial fibrillation and concomitant surgery for atrial fibrillation by a dedicated surgeon. In our open procedures, we have never encountered this complication.

We also like to state that the TTMAZE procedures were performed after a formal training and introduction program and were applied according to the instructions given by AtriCure.

The difficulty with this complication is the low rate of occurrence and the relatively long time frame between initial surgery and the occurrence of the complication. In this light, we advocate that our communication is seen as a matter of caution. There is a small potential of a highly devastating, even lethal, complication with this procedure.

We are convinced that these fistulas are not a single-center problem. The exact mechanism of this complication remains unclear. As we described, the lesion is seen centrally in the posterior wall of left atrium, away from the ablation lines.[3] The fistula needs several weeks (6–8) to develop and to cause septicemia and air embolism. This, in our view, seems to exclude a lesion caused by wrongly applied pressure or manipulation of tissue. Moreover, relatives of all the three patients reported well-being of patients until a day or even hours before collapse or neurological impairment.

To conclude, we agree that TTMAZE shows good results in treating lone atrial fibrillation. We also agree that the track record of TTMAZE is excellent in high-volume centres.[4] We do, however, warn about the potential complication of an atrio-esophageal fistula and emphasize the need for stringent follow-up of all patients and further research into the pathogenesis of this complication.