INTRODUCTION:Atrial-esophageal fistula is a rare, life-threatening complication of percutaneous radiofrequency catheter ablation involving the left atrium. We report a case of occult atrial-esophageal fistula associated with the development of acute respiratory distress syndrome in a patient who underwent pulmonary vein isolation for atrial fibrillation.
CASE PRESENTATION:A 56 year old male presented with dyspnea on exertion, abdominal distension, and constipation for 5 days. His past medical history was significant for hypertension, obstructive sleep apnea, hyperlipidemia, and atrial fibrillation. His mother had pulmonary fibrosis. He worked as a pipefitter for over 20 years. Ten months prior to admission, he was diagnosed with atrial fibrillation and atrial flutter. This persisted despite two attempts of cardioversion and amiodarone treatment. Five days prior to admission, he underwent percutaneous caval-tricuspid isthmus ablation and pulmonary vein isolation for his atrial fibrillation/flutter. Post-procedure he noted worsening abdominal distension, nausea, and constipation. Over the next few days, he developed shortness of breath with walking. On initial examination, the patient had a temperature of 100.7o F, a blood pressure of 125/82, heart rate of 87, respiratory rate of 24, and was saturating 99% on 2L oxygen via nasal canula. Lung exam revealed crackles bilaterally. Abdominal exam showed mild distension, quiet bowel sounds, and heme positive stool. White blood cell count was 10.7K, with no left shift. Hemoglobin was 12.5 gm/dl. Chest radiograph showed the presence of bilateral alveolar infiltrates. Chest CT with 3D reconstruction showed patent pulmonary veins, the presence of diffuse interstitial and alveolar infiltrates, and no evidence of atrial wall defects. Trans-esophageal echocardiogram with Doppler flow studies showed patent pulmonary veins and the presence of right heart dysfunction. Upper GI endoscopy showed gastritis and no evidence of hemorrhage. The patient developed worsening hypoxemic respiratory failure and acute respiratory distress syndrome requiring mechanical ventilation and had recurrent melena. Parenchymal lung biopsy showed the presence of diffuse alveolar damage on a background of usual interstitial pneumonia. The patient ultimately succumbed to progressive ARDS. Autopsy showed the presence of a 2 cm × 1 cm defect in the anterior esophageal wall communicating with the left atrium.
DISCUSSIONS:Atrial-esophageal fistula is a rare and usually fatal complication of percutaneous radiofrequency catheter ablation involving the left atrium. The anterior esophageal wall is separated from the posterior wall of the left atrium only by the pericardial sac, and is susceptible to thermal injury and fistula formation from radiofrequency catheter ablation at this point. Initial symptoms often are non-specific. Injury to the vagus plexus lining the esophagus is associated with evidence of gastric hypomotility such as constipation and bloating. Clinical manifestations of fistula formation may include hematemesis or melena, systemic embolic disease (CVA, seizures, digital infarcts), malaise, leukocytosis, persistent fever, bacteremia, or endocarditis. Identification of this complication is difficult and requires a high index of suspicion, with most cases discovered at autopsy. While most reports have described the development of systemic inflammation and sepsis in association with atrial-esophageal fistulae, none have reported an association with the onset of ARDS.
CONCLUSION:Atrial-esophageal fistula is a known complication of radiofrequency ablation involving the left atrium. Presenting signs and symptoms may be subtle, and include gastrointestinal bleeding, systemic and CNS emboli, severe sepsis, and in this patient, the development of ARDS.
DISCLOSURE:Nathan Sandbo, None.