Atrio-esophageal fistula
Contents
Background
- 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%) [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
- 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
- CT chest with contrast is the recommended modality, but repeat testing may be needed for eventual diagnosis [2]
- 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
See Also
External Links
References
- ↑ Nair KK, Danon A, Valaparambil A, Koruth JS, Singh SM. Atrioesophageal Fistula: A Review. J Atr Fibrillation. 2015;8(3):1331. Published 2015 Oct 31. doi:10.4022/jafib.1331
- ↑ Han H-C, Hui-Chen Han From the Austin Health, Ha FJ, et al. Atrioesophageal Fistula. Circulation: Arrhythmia and Electrophysiology. https://www.ahajournals.org/doi/full/10.1161/CIRCEP.117.005579. Published November 6, 2017. Accessed December 14, 2020.