Suspected atrioesophageal fistula complicated by coronary air embolism after catheter ablation for atrial fibrillation: direct angiographic visualization and catheter aspiration in a case report

Atrioesophageal fistula is a rare but fatal complication of catheter ablation for atrial fibrillation(AF). It may present with infection, dysphagia or other swallowing-related symptoms, neurologic events, and systemic air embolism; coronary air embolism is even less common. Case summary An 84-year-old woman was admitted with recurrent palpitations lasting 1 h, approximately 1 month after radiofrequency catheter ablation for atrial fibrillation and left atrial appendage closure(RFCA & LAAC). On admission, she was in sinus rhythm and had a normal cardiac troponin level. Four hours after admission, she abruptly became unresponsive and developed fever and severe respiratory abnormalities. Electrocardiography subsequently showed ST-segment elevation in leads II, III, and aVF. Emergency coronary angiography demonstrated gas in the mid right coronary artery with TIMI 0 distal flow, and catheter aspiration was performed. Computed tomography (CT) of the head and chest revealed gas at multiple sites, including the intracranial compartment, cardiac chambers, and great vessels. Blood cultures grew Streptococcus constellatus and other streptococci. Given the recent left atrial ablation, acute neurologic and myocardial ischemic manifestations, multisite intravascular gas, and bacteremia with organisms associated with the oropharyngeal or gastrointestinal flora, an atrioesophageal fistula complicated by systemic air embolism was strongly suspected. Her condition deteriorated rapidly, and she developed cardiac arrest and died approximately 27 h after admission. Conclusion Atrioesophageal fistula and coronary air embolism should be considered in patients who develop fever, impaired consciousness, or acute ST-segment elevation within several weeks of atrial fibrillation ablation. Coronary angiography can directly visualize intracoronary gas and allow catheter aspiration; however, the certainty of an atrioesophageal fistula diagnosis should remain commensurate with the available imaging evidence.