Neurological Consequences of Atrioesophageal Fistula After Radiofrequency Ablation in Atrial Fibrillation

Abstract

Background: Radiofrequency ablation for atrial fibrillation (RAF) is an increasingly performed procedure. It is performed during cardiac surgery or percutaneously by catheter. A dangerous complication of RAF is atrioesophageal fistula (AEF), which predominantly manifests neurologically owing to food embolism. Because neurologists may not be familiar with AEF and the prognosis is dependent on a prompt diagnosis, awareness of AEF by the neurologist may play a crucial role. Objective: To summarize for the neurologist the knowledge about fistula between the left atrium and esophagus occurring after RAF. Design, Setting, and Patients: Using a MEDLINE search, we collected reports about AEF after RAF in 28 patients. Main Outcome Measures: From the collected reports, the description of symptoms, diagnostic investigations, therapy, and outcome of the 28 patients were summarized. Results: In 28 cases, AEF developed 3 to 38 days after RAF. Confusion, grand mal seizures, meningitis, focal cortical signs, and postprandial transient ischemic attacks associated with fever were the leading manifestations in 21 of 28 patients. Blood tests showed leukocytosis, elevated serum C-reactive protein levels, and thrombocytopenia. Blood cultures were frequently positive for bacteria. Lumbar puncture revealed pleocytosis, elevated protein levels, increased lactate levels, and bacteria. Diagnosis was established by thoracic contrast computed tomography. Endoscopy, insertion of nasogastric tubes, and transesophageal echocardiography were detrimental, leading to an increase in fistula size and food or air embolism. Therapy comprised surgery (n=11) or temporary esophageal stenting (n = 1). The remaining patients died before attempted surgery or confirmation of the diagnosis. A neurological deficit persisted in 3 of the 9 surviving patients.

Life-threatening GI hemorrhage caused by atrioesophageal fistula: a rare complication after catheter ablation for atrial fibrillation

“…6,8 Patients typically present with nonspecific symptoms such as chest pain, fever, dysphagia, or hematemesis anywhere from 3 to 38 days after the procedure. 1,6,8 Neurologic abnormalities such as confusion, seizures, and postprandial transient ischemic attacks are common due to systemic embolization of focal food matter from the esophagus. Thoracic CT with oral and intravenous contrast has been described as the most useful diagnostic tool.…”

“…Sepsis and GI hemorrhage are also common with an overall mortality rate approaching 80%. [6][7][8] We report a case of life-threatening GI hemorrhage due to atrioesophageal fistula formation after radiofrequency catheter ablation for refractory atrial fibrillation.…”

“…5 Atrioesophageal fistula formation is by far the most devastating of these esophageal injuries and has an overall prevalence of Ͻ1%. 1,6 Patients typically present with neurologic symptoms due to widespread embolism of esophageal contents. Sepsis and GI hemorrhage are also common with an overall mortality rate approaching 80%.…”

Atrioesophageal Fistula After Percutaneous Transcatheter Ablation of Atrial Fibrillation

“…However, if an AEF is suspected, CT scan of the chest is the recommended diagnostic tool because transesophageal echocardiography was reported to be detrimental. 3 Because most of the patients die of neurological complications, we suggest that empirical antimicrobial therapy with high blood-brain barrier permeability should be initiated immediately in individuals with suspected AEF. …”

“…AEF is a rare but life-threatening complication of percutaneous catheter ablation, 2 with a mortality rate of 80%. 3 AEF after radiofrequency ablation for atrial fibrillation has a median time to appearance of 15 days, 3 and a long period of latency may hamper the diagnosis. However, if an AEF is suspected, CT scan of the chest is the recommended diagnostic tool because transesophageal echocardiography was reported to be detrimental.…”