Atrial-Esophageal Fistula a Devastating Complication of Atrial Ablation

Abstract

Purpose: A 64-year-old male reported shortness of breath after a viral illness. He was diagnosed with a non-ischemic cardiomyopathy and developed atrial fibrillation. Multiple attempts were made for direct current cardioversion; however, symptomatic atrial fibrillation persisted. He failed rate and rhythm control. The patient underwent a mini-MAZE procedure for ablation of the arrhythmia foci. Two weeks later, he presented to the hospital with persistent fevers. Blood cultures grew Streptococcus anginosus and salivarius, both normal flora of the GI tract. Trans-thoracic and trans-esophageal echocardiogram did not reveal endocarditis. CT did not identify an intra-abdominal abscess. X-ray of the mouth was negative for intra-oral abscess. During the hospitalization, the patient was noted to have acute left sided weakness. CT and MR of the brain revealed small foci of air emboli. CT of the chest revealed air the left atrium and a fistula between the left atrium and the esophagus. The patient was urgently transferred to a referral hospital for surgical repair requiring primary closure of the esophagus and a bovine patch covering the atria. Nine months later, the patient presented to our hospital with fevers. Blood cultures grew Fusobacterium. GI consultation was obtained by the cardiology service prior to trans-esophageal echocardiogram given the prior esophageal surgery. A barium esophagram revealed a small filling defect without evidence of perforation. An EGD was performed, visualizing suture material from the atrial patch, as well as the bovine atrial patch itself eroded into the esophagus. The patient underwent surgical repair for the recurrent fistula. He recovered from his bacteremia, surgery, and was discharged to rehabilitation. This case illustrates the classic constellation of symptoms of polymicrobial, normal flora bacteremia, with air embolism cerebrovascular accident (CVA) secondary to an atrial-esophageal fistula. This fistula carries high morbidity and mortality. Recognition of this complication from atrial ablation is critical. GI physicians should take close note given the normal flora, polymicrobial, bacteremia and air embolism CVA that is classic for this disease.Figure: No Caption available.