PO-01-075 TRANSTHORACIC ECHOCARDIOGRAPHY FOR EARLIER DIAGNOSIS OF ATRIOESOPHAGEAL FISTULA AFTER ABLATION FOR ATRIAL FIBRILLATION

Abstract

Atrioesophageal fistula (AEF) is a rare complication of radiofrequency ablation for atrial fibrillation (AF). Early diagnosis and surgical management are keys to mitigate progression of this often moribund complication. Although chest CT is the preferred first line imaging tool for diagnosis, AEF symptoms are often variable and counterintuitive which prompts the need to understand echocardiographic findings that may lead to an earlier diagnosis. To report the initial echocardiogram findings of two patients that were ultimately diagnosed with AEF. N/A A 79-year-old male with symptoms AF and gastroesophageal reflux underwent an uneventful pulmonary vein isolation (PVI). Approximately 3 weeks after the ablation, the patient presented to his local hospital with profound fatigue and was found to have nonspecific ST/T changes with an elevated troponin. The transthoracic echocardiogram (TTE) showed moderate left ventricular dysfunction and echo dense microbubbles in the left atrium and ventricle, but not in the corresponding right-sided chambers (Figure A). An emergent CT scan based upon the TTE showed an AEF and he underwent and emergent surgery to repair the AEF. A 49-year-old male underwent a PVI with additional targeting of regions of complex fractionated electrograms on the posterior wall. Two weeks later he developed worsening dyspnea on exertion and chest pain. A CT scan found multiple septic pulmonary emboli and a TTE noted a mobile density crossing the intra-atrial septum. During transfer to our center, he developed progressive respiratory failure and required intubation. Upon arrival he was found to have multiple embolic injuries to his brain and focal neurologic findings. A transesophageal echocardiogram (Figure B) confirmed the mobile density in the right atrium that was an extension of a lesion originating from the posterior left atrium and extending to the iatrogenic atrial septal defect. AEF requires very early diagnosis for survival. In the setting of often non-specific symptoms, such as in these two cases that can lead to an initial incorrect diagnosis, the TTE provided key information to support the underlying diagnosis and guide expedited work-up and intervention.