Lily K Fatula, BS1, William D Bolton, MD2, Barry R Davis, MD2, James E Stephenson, MD2, Sharon Ben-Or, MD1. 1University of South Caroline School of Medicine Greenville, 2Department of Surgery, Greenville Health System
This report describes presenting symptoms, diagnostic modalities, and survival outcomes in patients with left atrial esophageal fistula (AEF) secondary to catheter ablation for atrial fibrillation (AF), including two patients who recently presented to our institution within a 2-month timespan. Although rare, incidence of AEF is increasing and carries a high mortality rate. Approximately 50 reports of AEF following AF ablation have been described. Both patients at our institution presented with fevers and neurological deficits.
Patient 1, a 57-year-old man, presented 31 days post ablation with a fever and right-sided weakness. A chest CT showed gas in the left atrium and esophagus; an echocardiogram confirmed the diagnosis of AEF. The patient subsequently underwent a left thoracotomy. Post-operative recovery was poor and included acute tubular necrosis, liver failure, and worsening cerebral edema. The patient was removed from life support and expired on post-operative day (POD) 28.
Patient 2, a 77-year-old man, presented 21 days post AF ablation with left arm weakness and altered mental status. An esophagram was performed and showed no evidence of an esophageal perforation. The patient, however, was admitted and, following worsening conditions, underwent a head CT which showed pneumocephalus, leading to our suspicion of the AEF. A follow-up chest CT confirmed the AEF. Treatment included an esophagectomy and repair of the atrium. At this date (POD 6), the patient is alive, but remains on a ventilator. Fever, neurological deficits, hematemesis, altered mental status, and chest pain are the primary presenting symptoms in patients with AEF; these same symptoms were seen our patients. With regards to diagnostic modalities, chest CT and head CT are the leading methods reported. Head and chest CT also proved to be the most accurate diagnostic tools for our patients. Lastly, the reported mortality rate associated with AEF is 40-80%. However, the literature has shown speed of diagnosis and treatment to improve a patient’s chance of survival. In conclusion, we recommend that a chest CT be immediately performed on patients presenting with the described symptoms following a recent AF ablation.