Atrioesophageal Fistula: Considerations for the neurological clinician

Zima, Laura; Fornoff, Linden E.; Surdell, Daniel L.

doi:10.1016/j.clineuro.2018.04.029

Cited by 7 publications

(3 citation statements)

References 6 publications

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“…AEF awareness and prevention measures are inadequate. Several case reports and small series cases describe the clinical manifestations and prognosis of AEF [8,9]. However, the reports are heterogeneous.…”

Section: Introductionmentioning

confidence: 99%

Clinical Manifestations, Outcomes, and Mortality Risk Factors of Atrial-Esophageal Fistula: A Systematic Review

et al. 2021

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Introduction: Atrial-esophageal fistula (AEF) is a rare but life-threatening complication of catheter ablation. The clinical presentation and mortality risk factors of AEF have not been fully elucidated. The aim of this study was to systematically review the clinical characteristics and prognosis of AEF. Methods: PubMed was searched from inception to October 2020 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement protocol. Results: A total of 190 AEF patients were included. The mean age was 59.29 ± 11.67 years, 74.21% occurred in males, and 81.58% underwent radiofrequency ablation. AEF occurred within 30 days after ablation in 80.82% of patients and occurred later in patients presenting with neurological symptoms compared with other symptoms (median of onset time: 27.5 days vs. 16 days, p < 0.001). Clinical presentation included fever (81.58%) and neurological symptoms (80.53%). Chest computed tomography (abnormal rate of 91.24%) was the preferred diagnostic test, followed by magnetic resonance imaging of the brain (abnormal rate of 90.91%). Repeated testing improved diagnostic evaluation sensitivity. Distinctive imaging results included free air in the mediastinum (incidence rate of 81.73%) and air embolism of the brain (incidence rate of 57.53%). The overall mortality was 63.16%, with worse nonsurgical treatment outcomes compared with outcomes of surgical treatment (94.19% vs. 33.71%, p < 0.001). Conservative or stent intervention was an independent risk factor for mortality. Age (adjusted odds ratio, 1.063, p = 0.004), presentation with neurological symptoms (adjusted odds ratio, 5.706, p = 0.017), and presentation with gastrointestinal bleeds (adjusted odds ratio, 3.009, p = 0.045) were also predictors of mortality. Conclusions: AEF is a fatal ablation complication. AEF can be diagnosed using a combination of a clinical history of ablation, infection, or neurological symptoms and an abnormal chest CT. Our analysis supports that surgical treatment reduces the mortality rate.

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Section: Introductionmentioning

confidence: 99%

Clinical Manifestations, Outcomes, and Mortality Risk Factors of Atrial-Esophageal Fistula: A Systematic Review

et al. 2021

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“…Therefore, when the intra-abdominal pressure rises suddenly, the lower segment of the esophagus is more likely to rupture, resulting in EPF. Unlike its counterpart, the right esophagus is closely attached to the pleura, has no surrounding soft tissues, and is prone to esophageal fistula [ 6 ]. After the occurrence of EPF, gastric contents enter the chest through the fistula, causing infection and inflammation.…”

Section: Discussionmentioning

confidence: 99%

Bevacizumab-induced esophageal pleural fistula during maintenance therapy without radiation in lung cancer

Wang¹,

Thakur

Chen³

2021

BMC Pulm Med

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Background Esophageal pleural fistula (EPF) is a rare but fatal complication associated with bevacizumab use; however, cases reports of EPF caused by bevacizumab have not been previously published. Case presentation A 66-year-old male patient diagnosed with stage IV lung adenocarcinoma on April 24, 2020 received 6 cycles of platinum-containing dual chemotherapy combined with bevacizumab followed by three cycles of bevacizumab monotherapy. Five days before admission, he experienced chest tightness, dyspnea, and right chest pain. Bed-side X-ray examination revealed a massive right hydrothorax, and food was found in the extracted pleural effusion. EPF was further confirmed by upper gastrointestinal radiography after oral administration of iohexol. The patient underwent jejunostomy as the distal esophagus could not be identified on gastroscopy, and eventually died of septic shock on January 16, 2021. Conclusions It is necessary to pay attention to EPF during bevacizumab use in patients with or without risk factors.

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“…3 It is important to have a high index of suspicion for AEF in patients presenting with embolic stroke after an ablation. 6 A transthoracic echocardiogram may demonstrate air in the left side of the heart or pericardium; however, the test of choice is a CT of the chest with contrast to look for pneumomediastinum or pneumopericardium. Transesophageal echocardiogram is contraindicated in suspected AEF due to risk for further esophageal damage and potential for air embolization during esophageal insufflation.…”

Section: A C C E P T E Dmentioning

confidence: 99%

Clinical Reasoning: A 62-year-old man with history of catheter ablation presenting with recurrent strokes

2020

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A 62-year-old man presented with a syncopal episode followed by left hemiparesis. Symptoms started right after landing from a 2-hour flight. The week prior to presentation he had general malaise, nausea, vomiting, poor appetite. He was diagnosed with pneumonia and completed a course of cefdinir. His previous medical history was relevant for paroxysmal atrial fibrillation (AF) for which he underwent catheter ablation one month prior to presentation, when he was on apixaban, started 2 weeks prior to the procedure, and continued until the presentation to our hospital. Upon initial assessment in the emergency department, he was well-appearing, febrile to 39.8°C, with regular heart rate of 126 beats per minute. He had no facial weakness; there was left leg weakness with 1/5 strength and 3/5 arm strength bilaterally. Reflexes were brisk in both lower extremities, with plantar reflexes extensor on the left, flexor on the right. Cranial nerve,

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Atrioesophageal Fistula: Considerations for the neurological clinician

Cited by 7 publications

References 6 publications

Clinical Manifestations, Outcomes, and Mortality Risk Factors of Atrial-Esophageal Fistula: A Systematic Review

Clinical Manifestations, Outcomes, and Mortality Risk Factors of Atrial-Esophageal Fistula: A Systematic Review

Bevacizumab-induced esophageal pleural fistula during maintenance therapy without radiation in lung cancer

Clinical Reasoning: A 62-year-old man with history of catheter ablation presenting with recurrent strokes

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