Atrio-esophageal fistula

Background

Posterior view of the position and relation of the esophagus in the cervical region and in the posterior mediastinum.

Layers of the GI track: the mucosa, submucosa, muscularis, and serosa.

Esophagus anatomy and nomenclature based on two systems.

CT showing anatomic relationship between an enlarged left atrium (LA) and esophagus (ESO): atrium abuts and indents into the anterior wall of the esophagus.

• Rare but deadly complication of atrial ablation
• There have been reported cases with various ablation modalities (including radiofrequency ablation, cryoablation, high intensity focused ultrasound, and surgical ablation)
• Incidence is low (<0.1%)
• Usually formed between esophagus and left atrium
• Thought to be related to adverse healing secondary to esophageal injury during the ablation procedure

Clinical Features

• Most common presenting symptoms:
  • Fever
  • Neurological symptoms (including focal neurological symptoms, seizure, AMS)
  • Gastrointestinal symptoms (including hematemesis, melena, dysphagia, nausea/vomiting)
  • Chest pain
• Most common time frame to presentation is 2-4 weeks post procedure but can occur up to 2 months post procedure

Differential Diagnosis

• Sepsis
• Stroke/TIA
• GI bleed

Chest pain

Critical

• Acute coronary syndromes (ACS)
  • STEMI
  • Non-STEMI
  • Unstable angina
• Aortic dissection
• Cardiac tamponade
• Coronary artery dissection
• Esophageal perforation (Boerhhaave's syndrome)
• Pulmonary embolism
• Tension pneumothorax

Emergent

• Cholecystitis
• Cocaine-associated chest pain
• Mediastinitis
• Myocardial rupture
• Myocarditis
• Pancreatitis
• Pericarditis
• Pneumothorax

Nonemergent

• Aortic stenosis
• Arthritis
• Asthma exacerbation
• Biliary colic
• Costochondritis
• Esophageal spasm
• Gastroesophageal reflux disease
• Herpes zoster / Postherpetic Neuralgia
• Hypertrophic cardiomyopathy
• Hyperventilation
• Mitral valve prolapse
• Panic attack
• Peptic ulcer disease
• Pleuritis
• Pneumomediastinum
• Pneumonia
• Rib fracture
• Stable angina
• Thoracic outlet syndrome
• Valvular heart disease
• Muscle sprain
• Psychologic / Somatic Chest Pain
• Spinal Root Compression
• Tumor

Evaluation

Chest CT demonstrating pneumomediastinum after cardiac radiofrequency catheter ablation for refractory atrial fibrillation.

• CT chest with contrast is the recommended modality, but repeat testing may be needed for eventual diagnosis
• Endoscopy may be considered, but may be associated an increased risk of clinical deterioration
• Transthoracic and transesophageal echocardiography have not been found to be highly sensitive

Management

• Mortality is high in all patients
• Surgery has the best mortality benefit, followed by endoscopic intervention
• Nonintervention has the worst outcome

Disposition

• Admission
• Surgery consultation