Atrio-oesophageal fistula: dismal outcome of a rare complication with no common solution

Abstract

Atrio-oesophageal fistula caused by diffusion of ablative energy through the left atrial wall to the oesophagus is a lethal complication. A high level of suspicion, rapid diagnosis and early correction are of crucial importance. In this review, we highlight the key points that will aid in the thought processes and provide guidance in the prevention, early diagnosis and management to reduce complications and improve outcome when atrio-oesophageal fistula is suspected.

Iatrogenic atrio-esophageal fistula following a video-assisted thoracoscopic maze procedure: Is esophageal instrumentation justified even when the diagnosis is equivocal?

“…Whereas transthoracic echocardiography may be useful in some cases, TEE should be avoided to prevent further esophageal injury. [ 1 ] Similarly, EGD is usually contraindicated in the presence of AEF as it could potentially open the tissue flap and cause massive iatrogenic air embolism as well as life-threatening bleeding. [ 8 ] However, esophageal ultrasound has been proposed as an option when the diagnosis of AEF is extremely challenging.…”

“…[ 3 ] As the TEE probe is positioned directly behind the LA, the electrical charge over the head of the probe can interact with the electrocautery, especially if it is unipolar, and produce excessive heat in the area. [ 1 ] Moreover, the presence of a TEE probe may preclude the placement of a temperature probe and could potentially fix the esophagus in a position nearest to the posterior wall of the LA, theoretically increasing the risk of injury. [ 10 11 ] Severe gastroparesis following radiofrequency ablation has also been documented and may contribute to esophageal injury.…”

“…However, stenting should be reserved as a temporary bridge only. [ 1 18 ] When it is used, CO 2 should be used cautiously at very low flow rates, avoiding air as much as possible. Alternatively, it could be performed completely under fluoroscopy to prevent the insufflation of any gas.…”

“…Its incidence is estimated to be 0.01%–0.2% for ablations performed percutaneously but is much higher (1.0%–1.5%) when done surgically. [ 1 ] Video-assisted thoracoscopic (VATS) left atrial (LA) maze procedure is a minimally invasive epicardial approach that has been shown to be feasible and efficacious in treating persistent, recurrent AF. [ 2 ] We present the clinical dilemmas associated with the diagnosis and management of AEF which developed several weeks after our patient underwent this ablation technique.…”

Delayed Presentation of Cerebral Air Embolism from a Left Atrial-Esophageal Fistula: A Case Report and Review of the Literature

“…However, these findings are not required to make a probable diagnosis of left atrial-esophageal fistula following a recent cardiac intervention as seen in this case report. Of note, it is important to avoid any interventional diagnostic procedures such as transesophageal echocardiogram or esophagoscopy due to potential of introducing air embolism [ 8 ]. Sonmez, et al described a 58-year-old female who presented 22 days after her procedure with fever, chills and right arm numbness.…”