Atrio-Esophageal Fistula: A Case Series and Literature Review

Abstract

BACKGROUND Percutaneous catheter radiofrequency ablation (RFA) and cryoablation of the left atrium and pulmonary vein ostia have become successful therapeutic modalities in the management of atrial fibrillation. Atrio-esophageal fistula is a rare complication. Awareness of complication risk is imperative because without prompt diagnosis and urgent surgical intervention, the outcome is often fatal. We present 3 cases of atrio-esophageal fistula following percutaneous catheter radiofrequency ablation (RFA). CASE REPORT Case 1: A 72-year old white male presented 27 days after percutaneous RFA for atrial fibrillation with fever, altered mental status, and melena. Esophagogastroduodenoscopy (EGD) revealed a 1-cm defect in the mid-esophagus. Upon thoracotomy, severe hemorrhage ensued from a concomitant injury to the left atrium. Multiple attempts to repair the left atrial perforation were unsuccessful and the patient died. Case 2: A 71-year old white male presented 29 days after percutaneous RFA for atrial fibrillation with fever and tonic-clonic seizure. Recognition of possible atrio-esophageal fistula was considered and confirmed on thoracotomy. Surgical fixation of the left atria and esophagus were performed. The patient survived and was discharged to a skilled care facility. Case 3: A 75-year old white male presented 24 days after percutaneous RFA for atrial fibrillation with chest pain. An echocardiogram revealed a large pericardial effusion and pericardiocentesis was performed. Despite aggressive measures, the patient died. The autopsy demonstrated a communicating esophageal fistula with the right pulmonary vein. CONCLUSIONS Clinicians tending to patients who have recently undergone atrial ablation need to be aware of atrio-esophageal fistula as a rare but highly fatal complication.

Figure 1.

(A) Curvilinear foci of hypodensity seen adjacent to the right greater than left frontal sulci, representing air emboli within venous or arterial structures (yellow arrows). (B) Scattered foci of diffusion restriction in the bilateral hemispheres. (C) Multiple bilateral acute infarcts with distribution suspicious for embolic origin (yellow arrows).

Figure 2.

Esophagogastroduodenoscopy image depicting an approximate one centimeter defect in the midesophagus with viewable mediastinum representing the atrio-esophageal fistula.

Figure 3.

(A) CT Chest coronal view demonstrating a mild irregularity involving the mid-thoracic esophagus with tiny foci of adjacent extraluminal air and inflammatory change suspicious for perforation (yellow arrow). (B) CT Chest sagittal view demonstrating extraluminal anterior to the mid-esophagus and posterior to the left atrium (yellow arrow).

Figure 4.

(A) CT Chest coronal view demonstrating mediastinal air anterior to the esophagus and posterior to the superior aspect of the left atrium (yellow arrow). (B) CT Chest sagittal view demonstrating extraluminal air in the mediastinum (yellow arrow).

Figure 5.

(A) Autopsy image demonstrating the esophageal fistula opening. (B) Formalin-fixed autopsy image demonstrating the fistula track and opening in the left atrium.