Pus in the pericardium: a pericardial-oesophageal fistula with cardiac tamponade after ablation for atrial fibrillation

Background: Pericardial/atrial oesophageal fistula (PEF/AEF) is the most feared complication of cardiac atrial fibrillation (AF) ablation. Without urgent surgical treatment, most cases of this infrequent complication rapidly prove fatal. Case report: We present an uncommon case of a 60-year-old male who had undergone an AF ablation 2 weeks prior and presented with chest pain. Following diagnosis and treatment of ST-elevation myocardial infarction (STEMI), a small pericardial effusion was noticed on computed tomography (CT) scan. Despite an initially reassuring hospital course, rapid decompensation and expansion of his purulent pericardial effusion led to his death within 24 hours of presentation. A post-mortem review of his CT imaging revealed an inconspicuous PEF. Conclusions: It is essential to maintain a high suspicion of PEF/AEF in patients presenting after AF ablation with suggestive symptoms, such as fever, chest pain/odynophagia, and neurological deficits. CT chest is the most common diagnostic modality and surgical correction is the treatment of choice. LEARNING POINTS: Pericardial/atrial oesophageal fistula is a devastating complication of atrial fibrillation ablation and early detection is the keystone of effective management.Urgent surgical repair is the most effective treatment to prevent mortality.Preventative measures include power titration, limiting energy delivery times, and avoiding overlapping ablation lines during the ablation procedure.