Left Atrial to Esophageal Fistula: A Case Report and Literature Review

Abstract

BACKGROUND Left atrial to esophageal fistula (LAEF) is a rare fatal complication of radiofrequency ablation (RFA) for atrial fibrillation and is associated with high mortality. Clinical features can be nonspecific and include fever, dysphagia, upper gastrointestinal (GI) bleeding, sepsis, and embolic stroke a after recent history of RFA for atrial fibrillation. CASE REPORT A 57-year-old Caucasian male was brought to the emergency department (ED) by his family because of an altered mental status. He had undergone a radiofrequency ablation for paroxysmal atrial fibrillation three weeks earlier. Several hours after admission to the ED, the patient transiently became unresponsive and had a right sided hemiplegia. A brain MRI revealed multiple cerebral infarcts. On the following day, the patient had an episode of melena, and an esophagogastroduodenoscopy (EGD) was performed which did not reveal any source of bleeding. While the patient was being monitored in the intensive care unit (ICU), he had an episode of hematemesis and went into cardiac arrest from which he was successfully resuscitated and transferred to another facility. He had another EGD, which uncovered a flap of mucosa covering the lower third of his esophagus and a 1 cm fistulous opening was seen with fresh blood oozing out of it. The patient had another cardiac arrest during the endoscopy and died despite all measures. CONCLUSIONS We present this case to stress the importance of early diagnosis of LAEF. LAEF can be fatal if diagnosis is delayed or missed. Early surgical intervention can reduce LAEF morbidity and mortality. Newer diagnostic modalities such as endoscopic ultrasound (EUS) can be helpful in cases where conventional imaging is unclear.

Figure 1.

MRI of the brain showing multiple bilateral infarcts (white arrows).

Figure 2.

First EGD showing completely normal esophagus with no visible ulcers or fistulous opening.

Figure 3.

Image of sagittal section of chest CT with oral contrast showing air between left atrium and esophagus with oral contrast along posterior left atrial wall (black arrow).

Figure 4.

Image of the axial section of chest CT with oral contrast showing air near the posterior wall in the left atrium adjacent to esophagus (white arrow).

Figure 5.

Repeat EGD showing the 1 cm fistulous opening in the anterior wall of lower third of esophagus showing blood gushing out (black arrow).

Figure 6.

Chest CTA with contrast sagittal view, showing air in the mediastinum between esophagus and left atrium (white arrow).

Figure 7.

Chest CTA with contrast coronal view showing air in the mediastinum around the left atrium and pulmonary veins (white arrow).