Surgical technique for atrial-esophageal fistula repair after catheter ablation: An underrecognized complication

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  Successful surgical management of atrial-esophageal fistula (AEF) with 2-staged repair.

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  Video 1. Case details including workup, surgical approach, and techniques presented in a male with an atrial-esophageal fistula following catheter ablation. Video available at: https://www.jtcvs.org/article/S2666-2507(20)30360-6/fulltext.

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  Figure 1. Diagnosis and initial control of atrial-esophageal fistula via median sternotomy (stage 1): A 35-year-old man underwent pulmonary vein isolation and catheter ablation for AF. Three weeks following the procedure, he presented with chest pain and blurry vision. A, Diagnostic imaging including: (i) Computed tomography with intravenous contrast (yellow line represents distance from esophagus to the ostia of the pulmonary veins) and (ii) oral contrast given and images obtained with patient lying prone demonstrating contrast extravasation and air within the atrium (white arrow). B, Three-dimensional reconstruction of the left atrium (dotted white line) demonstrating air behind the atrium (black arrowhead) and atrial defect (highlighted in red). C, Initial stage of surgical repair was performed via median sternotomy and aortic/bicaval cannulation for cardiopulmonary bypass. Intraoperative gross photography highlighting the defect located in the posterior left atrial wall with surrounding inflammation (white arrowhead). Intracardiac repair was performed using a bovine pericardium patch, and the patient was separated from bypass. RIPV, Right inferior pulmonary vein; E, esophagus; LA, left…

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  Figure 2. Takedown and repair of atrial-esophageal fistula via right posterolateral thoracotomy (stage 2). Following intracardiac repair via median sternotomy, the patient was repositioned and a right posterolateral thoracotomy was performed. Diagram depicts surgical steps, including A, dissection of the esophagus and identification of the atrial-esophageal fistula. Penrose drains placed along proximal and distal portions of the esophagus to aid in exposure. B, Division of esophageal fistula using TA 30-mm green (4.8 mm) staple load. Staple line placed close to the esophagus to avoid disruption of the pericardium and before intracardiac repair. C, Repair of the esophageal defect in layers. D, Intercostal muscle flap (harvested on entry) placed between the pericardium and esophageal repair, secured with four horizontal mattress 4-0 absorbable VICRYL sutures. The repair was then evaluated with intraoperative endoscopy and a leak test was negative. Up until this point, endoscopy was completely avoided and the patient was maintained in slight Trendelenburg to decrease the risk of cerebral air embolism. E, Esophagus; P, pericardium; AEF, atrial-esophageal fistula; D, diaphragm.