Case Presentation:
A 65-year-old male presented with sharp severe chest pain, worsened with respiratory movements. One day prior to admission, patient had catheter ablation due to persistent atrial fibrillation. He had no other medical history. Initial echocardiogram was normal and pericarditis treatment was started. Two days later, patient’s symptoms worsened: nausea and odynophagia. Repeat bedside echocardiogram showed pericardial effusion. Esophagogram with gastrografin was consistent with extravasation of contrast in left lateral distal esophagus. Chest computed tomography showed an esophago-pericardial fistula. Pericardial effusion was drained through median sternotomy. EGD revealed a medium-sized fistula in the middle third of the esophagus at 32 cm. A 20 mm x10 cm partially-covered controlled-release stent with a 25 mm flange under fluoroscopic guidance was deployed. Patient was kept NPO with broad spectrum antibiotics. Five days post stenting, repeat esophagogram did not show leakage and tube feeds through nasogastric tube started. Patient was transferred to inpatient rehabilitation program.
One month post ablation, patient had new onset left sided paresthesia and weakness. Stroke workup was initiated, and echocardiogram showed a highly mobile left atrial mass. Accordingly, emergent left atriotomy was done. The thrombus was removed and a nickel-sized hole was found in the back of the left atrium which appeared to be fused with the esophageal wall outside the visible esophageal stent. The defect was repaired with autologous pericardium.
Discussion:
Esophageo-Atrial fistulas are very uncommon complication following atrial fibrillation catheter ablation procedures, with incidence ranging between 0.05 to 1.5%. Timing of presentation varies, with a mean of 19 days post ablation. The mechanism for the fistula formation is still not completely understood but is highly suspected that the proximity of the esophagus and the left atrium with a thermal transmission may damage the tissues. Gastric acid reflux might also be implicated. Esophageal perforation treatments have been described , including insertion of covered or partially-covered stents, as in our patient. The stenting was successful, but the course was later complicated by an atrial perforation.
Conclusions:
As hospitalists, we manage patients who underwent cathter ablation very often and such a complication is very unusual. Complications of these fistulas can be devastating if not treated early and physicians should be aware of such entity.