An esophageal-pleural fistula following transesophageal echocardiography-guided left atrial appendage closure: a case report

Periprocedural complications of left atrial appendage occlusion (LAAC) are varied and potentially life-threatening. We report a rare case of an iatrogenic esophageal-pleural fistula following a TEE-guided LAAC procedure. A 77-year-old woman with atrial fibrillation and a contraindication to long-term anticoagulation underwent successful LAAC. Her post-operative course was complicated by a pneumothorax and persistent pleural effusion. The diagnosis of an esophageal-pleural fistula was established after analysis of the chest tube drainage revealed food particles. Given her age and active infection, a non-surgical, conservative management strategy was adopted, involving complete gut rest, broad-spectrum antibiotics, thoracic lavage, and enteral nutrition support. The fistula closed after 52 days of conservative management, confirmed by follow-up imaging. This case underscores that while TEE-related esophageal injury is exceedingly rare, it must be considered in cases of persistent post-procedural pleural effusion. Furthermore, it demonstrates that in selected high-risk patients, a conservative approach can be a viable management option. The decision to perform a pre-procedural upper GI evaluation remains complex, given the very low incidence of this complication.