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Progressive Embolic Infarction Secondary to Air Emboli From Atrioesophageal Fistula Status Post Left Atrial Ablation for Atrial Fibrillation: A Case Report

Louis Moyer, MD
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Pulmonary, Walter Reed National Military Medical Center, Bethesda, MD


Chest. 2014;146(4_MeetingAbstracts):418A. doi:10.1378/chest.1995243
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Abstract

SESSION TITLE: Miscellaneous Cases I

SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Sunday, October 26, 2014 at 10:45 AM - 12:00 PM

INTRODUCTION: Atrioesophageal fistula (AEF) is a life-threatening complication of left atrial ablation for atrial fibrillation. AEF resulting in embolic stroke is rare and difficult to recognize, but prompt diagnosis may increase options for repair and survival.

CASE PRESENTATION: A 70-year-old female with a PMH significant for atrial fibrillation on warfarin underwent two left atrial ablations within 10 days. She later presented with sudden onset left sided paresthesias and weakness as well as distributive shock from presumed sepsis. Blood cultures were positive for Viridans Streptococci and she was treated appropriately with antibiotics. Initial head CT suggested watershed infarcts in the right MCA territory. Neurologic symptoms waxed and waned until ICU day three when she developed signs of a sudden increase in intracranial pressure, and MRI/MRA revealed a right hemispheric infarct. An emergent decompressive hemicraniectomy was performed, though exam remained poor. A repeat head CT showed several new infarctions suggestive of embolic stroke. A TTE was negative for endocarditis or PFO. A chest CT then confirmed the diagnosis of AEF. Cardiothoracic surgery and GI surgery were emergently consulted and an esophageal stent was placed.

DISCUSSION: AEF as a complication of ablation are reported in <1% in recent worldwide surveys. This rare complication can have devastating neurological consequences and fatal in over 70%. Death mainly occurs from cerebral air embolism, GI bleeding, and septic shock. Successful treatments of AEF with surgery and esophageal stenting have been published in prior case reports. However, survival rates with these interventions are poor and general consensus for optimal management is lacking.

CONCLUSIONS: AEF is a rare but fatal complication of catheter ablation. Diagnosis should be considered in patients presenting with neurologic findings and septic shock following the procedure.

Reference #1: Tan C, Coffey A. Atrioesophageal fistula after surgical unipolar radiofrequency atrial ablation for atrial fibrillation. Ann Thorac Surg. 2013 Mar;95(3):e61-2.

Reference #2: Cappato R, Calkins H, Chen SA, Davies W, Iesaka Y, Kalman J, Kim YH, Klein G,Natale A, Packer D, Skanes A. Prevalence and causes of fatal outcome in catheter ablation of atrial fibrillation. J Am Coll Cardiol. 2009 May 12;53(19):1798-803.

Reference #3: Haggerty KA, George TJ, Arnaoutakis GJ, Barreiro CJ, Shah AS, Sussman MS.Successful repair of an atrioesophageal fistula after catheter ablation for atrial fibrillation. Ann Thorac Surg. 2012 Jan;93(1):313-5.

DISCLOSURE: The following authors have nothing to disclose: Louis Moyer

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