3102 Atrio-Esophageal Fistula Presenting as Odynophagia: A Rare but Fatal Complication of Cardiac Ablation

Abstract

INTRODUCTION: Atrio-esophageal fistula is one of the challenging complications of catheter ablation. The clinical presentation is unpredictable but rapid diagnosis and surgical treatment may prevent fatality. We are here reporting a case of a patient who initially presented with odynophagia and was diagnosed later with atrio-esophageal fistula. CASE DESCRIPTION/METHODS: 43 years old male presented to ED with complaints of retrosternal chest pain and odynophagia s/p cardiac ablation for AF 4 days ago. Initial investigation were normal. Patient on upper GI series had focal contrast collection at the distal esophagus. Patient underwent EGD and it was found that patient had linear deep mid esophageal perforation for which 6 hemostatic clips were used for closure patient was discharged on TPN. After 2 weeks patient presented again for shortness of breath and chest discomfort. On examination patient had loud pericardial friction rub suspicious and stat Echo showed pericardial effusion with early signs of cardiac tamponade. Patient underwent emergent pericardiocentesis. After pericardiocentesis patient became febrile and blood cultures were growing Lactobacillus. CT chest (pulmonary veins) revealed Atrio-esophageal fistula, pericardial effusion and left sided pleural effusion suspected for empyema. Patient underwent thoracotomy, decortication of empyema, repair of inferior pulmonary vein/atrial margin, esophageal repair, G/J tube placements, and omental transfer. Patient eventually improved and was discharged home. DISCUSSION: The estimated incidence of atrio-esophageal fistula is less than 0.1% – 0.25% after AF ablation procedures. Potential culprit is direct heat of radiofrequency ablation causing damage to already susceptible epithelial esophageal mucosa. After esophageal mucosal necrosis, fistula formation and mediastinitis can occur. Pericardial effusion/tamponade, sepsis and cardioembolic stroke can also occur. Patient may present with fever, nausea, vomiting, dysphagia, odynophagia, hematemesis and melena. CT scan of the chest with intravenous contrast is considered by many as the diagnostic modality of choice as it can identify the leak along with any signs of pneumomediastinum and pneumopericardium. Endoscopy should be avoided as blowing of air inside can result in dislodging of the large embolus to the brain resulting in stroke or death. Treatment options include open surgical repair of fistula via thoracotomy with placement of tissue/omentum between esophagus and left atrium or esophageal stenting.