Atrio-oesophageal fistula after transcatheter radiofrequency ablation

Abstract

A 68-year-old woman presented 3 weeks following unsuccessful transcatheter radiofrequency ablation (TcRFA) for treatment of her chronic atrial fibrillation. Neurological signs manifested on day 2 of admission with generalised tonic-clonic seizures and reduced Glasgow Coma Score. She was treated for presumed central nervous system (CNS) infection, intubated and transferred to the intensive care unit. CT of the head showed bilateral oedema secondary to acute embolic stroke. Blood cultures grewStreptococcus viridans, and lumbar puncture findings were consistent with CNS infection. Echocardiography showed only a septostomy puncture from the atrial fibrillation ablation procedure. Thoracic CT demonstrated air in the left atrium, consistent with the diagnosis of atrio-oesophageal fistula, a rarely reported iatrogenic complication of TcRFA. MRI of the head showed significant neurological injury with innumerable embolic infarcts. After discussion with her family regarding the significant neurological insult, and with no signs of any clinical improvement, the patient died on day 8 of admission.

Atrio-Esophageal Fistula: A Case Series and Literature Review

“…This can be compounded by the esophagus proximity to the posterior wall of the left atrium, often separated by a thin layer of fat a few millimeters thick. This is supported by evidence that an estimated 30% to 47% of all patients who undergo radiofrequency atrial ablation have some degree of injury to the esophagus mucosal layers [ 11 , 20 , 21 ]. Thermal injury from ablation leads to ischemic necrosis of the atrium and esophageal mucosal layers, creating the fistula [ 12 ].…”

“…It is imperative that physicians recognize the signs and symptoms of atrio-esophageal fistula. Time from ablation to symptom onset has been reported to be from 2 days to 5 weeks, with the most common occurrence at 10 to 17 days [ 4 , 11 , 23 , 24 ] Most patients present with the constellation of fever and neurologic deficits, often secondary to air emboli [ 24 – 26 ]. Less commonly, there is septicemia with oral flora bacteremia, chest pain, and hematemesis/melena [ 24 – 26 ].…”

“…Presentation of the described patients was delayed, with symptoms first appearing 21 to 29 days after ablation. It is important to note that when atrio-esophageal fistula is suspected, instrumentation of the esophagus with esophagogastroduodenoscopy (EGD) or trans-esophageal echocardiogram (TEE) is contra-indicated, as insufflation of the esophagus can result in the formation of air emboli causing neurologic injury and death [ 7 , 11 , 24 , 25 ]. In the first presented case, EGD was performed due to a life-threatening gastrointestinal bleed and occurred before the diagnosis of atrio-esophageal fistula was made.…”

“…It is important that when atrio-esophageal fistula is suspected, insufflation of the esophagus with either EGD or TEE be avoided. The most reliable modality for diagnosis is a CT of the chest with contrast, demonstrating extraluminal air or pneumomediastinum, air in the atrium, or the presence of intravenous contrast within the esophagus [ 7 , 11 , 26 , 27 ]. In the first case described, CT chest without contrast was performed because the diagnosis was not suspected.…”

“…When atrio-esophageal fistula is suspected, it is recommended that a CT chest with contrast be performed as it remains the test of choice. The overall mortality of atrio-esophageal fistula has been estimated at 40–80% [ 8 , 11 , 12 , 25 ]. A 2016 review by Khan et al found an estimated mortality rate of 71% [ 4 , 5 ].…”