Atrio-esophageal fistula

Background

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

Emergent

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

Nonemergent

• Stable angina
• Asthma exacerbation
• Valvular Heart Disease
• Aortic Stenosis
• Mitral valve prolapse
• Hypertrophic cardiomyopathy
• Pneumonia
• Pleuritis
• Tumor
• Pneumomediastinum
• Esophageal Spasm
• Gastroesophageal Reflux Disease (GERD)
• Peptic Ulcer Disease
• Biliary Colic
• Muscle sprain
• Rib Fracture
• Arthritis
• Costochondritis
• Spinal Root Compression
• Thoracic outlet syndrome
• Herpes Zoster / Postherpetic Neuralgia
• Psychologic / Somatic Chest Pain
• Hyperventilation
• Panic attack

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