An 86-year-old female developed a fatal atrio-esophageal fistula one month after radiofrequency ablation for atrial fibrillation, presenting with nonspecific symptoms and neurological deficits.
Case Report (n=1)
This case highlights the importance of maintaining a high index of suspicion for atrio-esophageal fistula in post-ablation patients presenting with nonspecific symptoms or neurological deficits to facilitate early diagnosis.
Abstract Introduction Catheter ablation (CA) for atrial fibrillation (AF) received a Class I indication for first-line therapy in selected patients in the American College of Cardiology guidelines in 2023. Currently, 50,000-100,000 catheter ablation procedures are performed annually in the United States. Atrio-esophageal fistula (AEF) is a rare but life-threatening complication of radiofrequency ablation (RFA), described in 0.03% - 0.08% of cases. With the growing adoption of CA, the incidence of this complication may increase, and early recognition by intensivists is critical. Case description An 86-year-old female with AF status post RFA one month ago and dual chamber pacemaker placed 2 years prior was found unresponsive by her husband. Emergency medical services (EMS) were called, and she was intubated in the field. She presented to the emergency room as a code stroke. On neurological evaluation, no localizing signs were present, and computed tomography angiography (CTA) of head and neck were normal. The patient’s family reported that she had experienced dysphagia and loss of appetite the week prior. Laboratory workup was significant for leukocytosis, lactic acidosis, and mild troponin elevation. Electrocardiogram showed AF and chest radiograph was unremarkable. She was placed on broad-spectrum antibiotics. CT chest/abdomen were obtained, and a small volume of air was noted within the left atrial appendage, raising suspicion for AEF (figure 1). Blood cultures later grew Streptococcus salivarius. Cardiac surgery was consulted, and the patient underwent emergent open-heart exploration. Intraoperatively, she developed severe hemodynamic instability, and after discussion with family, comfort measures were initiated. Discussion Due to the anatomic proximity of esophagus and posterior wall of left atrium (LA), thermal injury to the esophageal mucosa can occur during RFA. Subsequently, esophageal ulceration can lead to the formation of a one-way valve fistula from esophagus to LA. The median time from procedure to clinical presentation is 21 days. Presenting symptoms can be non-specific with fevers, dysphagia, chest pain, and focal neurological deficits being common. Bacteremia caused by oral cavity or gastrointestinal organisms is also commonly reported. CT Chest with contrast is the preferred modality for diagnosis. In literature, surgical repair of the atrial and esophageal defect has shown higher success rates than endoscopic interventions. However, overall mortality remains greater than 50% despite intervention. Our case highlights the importance of keeping a high index of suspicion for AEF in post-ablation patients, particularly when they present with nonspecific symptoms, to facilitate early diagnosis and prompt management. This abstract is funded by: None
Parmar et al. (Fri,) conducted a case report in Atrio-esophageal fistula after radiofrequency ablation for atrial fibrillation (n=1). Radiofrequency ablation was evaluated. An 86-year-old female developed a fatal atrio-esophageal fistula one month after radiofrequency ablation for atrial fibrillation, presenting with nonspecific symptoms and neurological deficits.