Pericardioesophageal Fistula Following Left Atrial Ablation Procedure

Abstract

We present a case of pericardioesophageal fistula formation in a 40 year old male who 23 days after undergoing a repeat ablation procedure for atrial fibrillation developed chest pressure, chills and diaphoresis. After initial labs and tests that demonstrated no evidence for acute myocardial ischemia, the patient underwent CT angiography of the chest. The study revealed pneumopericardium and a pericardial effusion. Suspicion was raised of perforation of the posterior left atrial myocardial wall with injury to adjacent esophagus. Water soluble contrast with transition to barium sulfate esophagram subsequently performed identified a perforation further affirming the postulate of a fistulous communication between the esophagus and pericardium. Transthoracic echocardiogram confirmed pericardial effusion but did not demonstrate myocardial defect. Endoscopic management was preferred and an esophageal stent was placed. Follow up esophagram showed an intact esophageal stent without evidence of extravasation.

Pericardial-esophageal Fistula Complicating Atrial Fibrillation Ablation Successfully Resolved after Pericardial Drainage with Conservative Management

“…Previous case studies reported that pericardial-esophageal fistula was successfully treated with supportive care or endoscopic intervention. 6) 7) 8) 9) In this case, pericardial-esophageal fistula was successfully healed by very strict fasting over 2 weeks with fluid and antibiotic therapy after drainage of inflammatory body fluids. Although a proton pump inhibitor was empirically administered after ablation due to the possibility of esophageal injury, esophageal perforation eventually developed.…”

“…Clinical detection of a pericardial-esophageal fistula can be difficult because conspicuous signs, such as systemic embolization and gastrointestinal tract bleeding, are not present. 6) 7) 8) 9) Therefore, to recognize the condition and avoid delay of an appropriate diagnosis, clinical suspicion should increase if there are any chest symptoms or signs suggestive of extensive tissue injury. In this case, after AF ablation, the patient complained of persistent retrosternal pain for more than 9 days, which is suggestive of extensive tissue injury.…”

“… 4) 5) However, it has been reported that pericardial-esophageal fistula can be managed non-surgically. 6) 7) 8) 9) We report a case of pericardial-esophageal fistula complicating AF ablation that was successfully managed with a conservative approach.…”

Atrio-Esophageal Fistula: A Case Series and Literature Review

“…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 ].…”

Esophago‐pericardial fistula after catheter ablation of atrial fibrillation: A review

“…When reviewing the literature regarding esophago-mediastinal fistulous formation, we found 23 cases of esophageal perforation without a fistulous communication with the left atrium. 6,7,[11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26] Only one of the 23 cases was screened early after ablation having a normal esophagoscopy, before developing perforation two weeks later 4 (Table 1). Park et al 4 also reported that another patient, who likely died of esophageal-atrial fistula, had a normal endoscopy on the second day after the procedure.…”