Life-threatening left atrioesophageal fistula complicated with catheter ablation for atrial fibrillation in a patient with aortic stent graft

A 75-year-old female with a history of total arch replacement and stent graft placement in the descending aorta underwent her second ablation procedure for atrial fibrillation, during which left atrial posterior isolation was performed (A). Nine days after the ablation, she was readmitted due to chest pain, and an upper gastrointestinal endoscopy revealed oesophageal ulceration (F-1). Twenty days after the ablation, she experienced transient left-side hemiparalysis, and a CT scan diagnosed a left atrioesophageal fistula with air in the mediastinum and ascending aorta (B). A transient ST elevation, suggesting air embolization into the coronary artery, was also recorded that night (C). After consulting with a cardiovascular surgeon and a gastroenterologist, an emergency surgery combining fistula closure using an autologous pericardial patch via left atrial approach and endoscopic oesophageal stent placement was performed (D, E, F-2). Her post-operative recovery was uneventful, and the oesophageal stent was removed 41 days after the surgery. On the 71st post-operative day, she was discharged ambulatory after confirming the healing of the ulcer (F-3). In this case, we could diagnose an atrioesophageal fistula immediately after multiple air embolizations into the brain and heart. It is assumed that the aortic stent graft not only served as a stiff structure to strengthen catheter contact with the oesophagus but also potentially contributed to the temperature rise in the oesophagus. The hybrid therapy with left atrial patch closure and oesophageal stent placement appears to be a suitable approach for treating atrioesophageal fistulas in very sick patients with severe underlying diseases. Supplementary data are not available at European Heart Journal online. All authors declare no conflict of interest for this contribution. No data were generated or analysed for this manuscript.