INTRODUCTION: Increased utilization of cardiac radiofrequency catheter ablation for the treatment of refractory atrial fibrillation has resulted in an increased prevalence of complications requiring ICU admission. We report a case of an atrial-esophageal fistula as a complication of cardiac radiofrequency catheter ablation.
CASE PRESENTATION: A 66 year-old Caucasian man with refractory atrial fibrillation who underwent a second cardiac radiofrequency catheter ablation 4 weeks prior was admitted with weakness, dysphagia, nausea, and vomiting. His weakness began 1 week after the procedure and gradually progressed to the point of being unable to carry out daily activities. He denied any fevers, chills, chest pain, palpitations, cough, or melena. Vital signs revealed a temperature of 101.7, blood pressure 85/58 mm Hg, heart rate 116 bpm, and oxygen saturation 96% on room air. Physical examination was remarkable for an irregularly irregular heart rate and bibasilar inspiratory crackles. White blood cell count was elevated at 16,600 with neutrophilic predominance and no bandemia. Hemoglobin was at baseline. Electrocardiogram showed atrial fibrillation with rapid ventricular rate and no ischemic changes. Chest radiograph revealed mild pulmonary edema with no cardiomegaly. The patient was treated with early goal-directed therapy for septic shock and started on empiric antibiotics for suspected healthcare-associated infection. Blood cultures were positive for gamma-hemolytic streptococcus. Transthoracic echocardiogram revealed a normal ejection fraction with no thrombus or valvular vegetation visualized. A computed tomography of the chest with intravenous radiocontrast revealed a gas bubble within the left atrium near the level of the esophagus, concerning for an atrial-esophageal fistula. The patient progressively became more confused and lethargic with no focal deficits on physical examination. Given concerns for intracranial air emboli, he was intubated and underwent hyperbaric therapy. His mental status improved significantly. MRI of the brain revealed multifocal ischemic infarcts thought to be secondary to air emboli. Surgical intervention to repair the atrial-esophageal fistula was considered too high risk in this patient. He clinically improved with conservative medical management.
DISCUSSION: As the utilization of cardiac radiofrequency catheter ablation for the treatment of refractory atrial fibrillation increases, there is an increased prevalence of complications. Formation of an atrial-esophageal fistula due to thermal injury of the esophagus is a very rare complication with only 49 cases reported in the literature. Diagnosis is complicated by the clinical variability of presentation. Patients present from 3 to 41 days after the procedure with nonspecific symptoms, including fever, leukocytosis, neurologic symptoms, chest pain, and odynophagia (1,2). Bacteremia and endocarditis are rare findings (1). Radiographic imaging revealing pneumomediastinum or intra-atrial air is the most useful diagnostic tool (1,2). Atrial-esophageal fistula is associated with a very poor prognosis. In the documented cases, mortality was 100% in patients who did not receive a therapeutic intervention and 40% in patients who underwent surgical correction. One case of esophageal stent placement has been reported. Hyperbaric therapy for the treatment of neurologic symptoms associated with an atrial-esophageal fistula has not been reported. This patient continued to clinically improve with conservative medical management.
CONCLUSIONS: Atrial-esophageal fistula must be considered in patients presenting with nonspecific symptoms after cardiac radiofrequency catheter ablation.
Reference #1 Siegel M, et al. Atrial-esophageal fistula after atrial radiofrequency catheter ablation. Clinical Infectious Disease 2010, 51(1): 73-76.
Reference #2 Takahashi A, et al. Complications in the catheter ablation of atrial fibrillation - incidence and management. Circulation Journal 2009, 73: 221-226.
DISCLOSURE: The following authors have nothing to disclose: Matthew Lester, Bela Patel
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