Atriobronchial Fistula Complicated by Septic Cerebral Air Emboli After Pulmonary Vein Ablation

Abstract

Clinicians should be aware of the dramatic complications of invasive antiarrhythmic procedures and their atypical and late presentations. Better preprocedural appreciation of cardiac wall thickness, early echocardiographic diagnosis, and swift referral for cardiac surgery might impact outcome dramatically.

Bronchial Safety After Pulsed Field Ablation for Paroxysmal Atrial Fibrillation

“…22 Severe complications, like persistent or massive hemoptysis and even atriobronchial fistula are rare but can be life-threatening. 6,23,24 The mechanism for development of atriobronchial fistula is not fully understood, but might be similar to the mechanism of atrioesophageal fistula formation.…”

“…Despite continuous efforts to refine ablation strategies and titrate energy delivery, all these techniques still cause collateral damage to cardiac and extracardiac tissue, like the esophagus and the bronchus. [2][3][4][5][6][7][8][9] For this reason, delivered energy levels must be reduced, leading to decreased efficacy and subsequent durability of the ablation lesions.…”

Surgical Strategies for Cardiac Perforation After Catheter Ablation or Electrophysiology Study

“…30) Acute onset of cardiac perforation following catheter ablation or EPS usually leads to immediate hemodynamic compromise. However, for the patients with delayed onset of cardiac perforation, there are different presentations, such as sepsis or neurological deficit due to LA esophageal fistula or LA bronchial fistula 25,26) in addition to hypotension. It is usually insidious for delayed onset of cardiac perforation, but it is still possible to be presented as sudden collapse.…”

Protecting Against Collateral Damage to Non-cardiac Structures During Endocardial Ablation for Persistent Atrial Fibrillation

“…AEF has been stubbornly resistant to this progress, with an incidence remaining at approximately 0.01–0.3% over the past two decades. [ 5 , 9 ] Evidence of milder thermal oesophageal injury ( Figure 3 ) can be found in as many as 47% of cases. [ 11 ] As other complications decline, and as procedure numbers increase, AEF becomes ever more important.…”

“…[5][6][7][8] Fistulae from the atrium to a bronchus have also been reported; like AEF, they are often lethal. 9 The true incidence of atriobronchial fistulas is not known, but radiological studies have highlighted the close proximity of the lung to the left atrium (Figure 2), in particular along the course where ablation of the pulmonary veins would be performed. 10 Nerves are also vulnerable, particularly the perioesophageal neural plexus and the phrenic nerves.…”