Atrial-Esophageal Fistula After Catheter Ablation: Diagnosing and Managing a Rare Complication of a Common Procedure
Challenging differential diagnosis, Diagnostic / therapeutic accidents, Management of emergency care, Rare co-existance of disease or pathology
Robby Singh, Elise J. Landa, Christian Machado
(Department of Cardiology, Providence Hospital, Michigan State University, Detroit, USA)
Am J Case Rep 2019; 20:557-561
Atrial fibrillation is considered the most common cardiac arrhythmias in the United States with rate and rhythm control strategies traditionally used for management. If patients are intolerant to class I or class III anti-arrhythmic medications, catheter ablation may be used as a rhythm control strategy. As catheter ablation becomes more commonplace, so too do the procedure-related complications, which include tamponade, total arterio-venous fistula, pulmonary vein stenosis, and atrial-esophageal fistula.
CASE REPORT: A 67-year-old male underwent catheter ablation for atrial fibrillation and subsequently presented with complaints of fever and chills. Initial workup for a source of infection included a computed tomography (CT) scan and transesophageal echocardiogram which did not reveal any abnormalities. Antibiotic therapy was initiated, and multiple CT scans were performed; eventually patient was found to have an atrial-esophageal fistula, secondary to thermal injury. The patient underwent thoracotomy and full thickness necrosis of the posterior left atrium and pericardium near the base of the left inferior pulmonary vein was visualized, with a roughly nickel sized orifice, which was repaired. The patient had an uneventful recovery and was doing well on follow-up.
CONCLUSIONS: Atrial-esophageal fistula is a rare but lethal complication of atrial fibrillation ablation. While imaging modalities have improved and can detect the condition, they can also yield ambivalent findings which can challenge patient care. It is important for clinicians to maintain a heightened awareness of this complication in post-ablation patients and utilize clinical history and not rely solely on imaging to diagnose and treat this complication.
Keywords: Atrial Fibrillation, delayed diagnosis, Esophageal Fistula, Postoperative Complications