SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Esophageal perforation is an uncommon complication that carries significant morbidity and mortality (as high as 67.7% and 19.9%, respectively)1. It is commonly associated with advanced esophageal carcinoma, chemical injury after ingestion, radiation therapy, iatrogenic injury 55% , spontaneous perforation , foreign body and traumatic penetrating injury.2 CASE PRESENTATION: We present the case of a 67-year-old female with history of coronary artery disease, aortic stenosis, mitral and tricuspid insufficiency who underwent a 2-vessel CABG, tricuspid valve repair, aortic and mitral valve replacements. The patient’s micrognathia prevented intraoperative transesophageal echocardiography. On postoperative day 14, the patient developed a fever with a right sided pleural effusion requiring a chest tube. Over a period of 24 hours chest tube drainage turned milky white from straw colored. Fluid cultures grew multi-drug resistant pseudomonas, and the patient was started on appropriate antibiotics. On day 24, pink fluid resembling the patient’s strawberry supplement shakes was present in the chest tube drain. CT esophagram found contrast in the dependent portion of the right subpleural space, consistent with an esophagopleural fistula (figure 1). EGD showed a 5 cm esophageal opening starting approximately 30 cm from the incisors. This was treated with an esophageal stent, J-tube feedings and antibiotics. DISCUSSION: This case has several notable features in its presentation and its etiology remains unclear. The patient had no significant risk factors preoperatively that would have predisposed her to esophageal perforation. She did not have cirrhosis with esophageal varices or alcoholic history prominent in Booerhaves nor did she have a previous esophageal cancer history. The patient also had no transesophageal echocardiogram (TEE) performed or intra-operative trauma to the esophagus. If there had been an intraoperative occult injury of the esophagus, then it would have been anticipated much earlier. CONCLUSIONS: An esophagopleural fistula is a rare complication that can present after cardiothoracic surgery. As in this case, it can present as late as 4 weeks postoperatively. CT esophagram is the diagnostic method of choice and treatment requires prompt intervention with either a GI or thoracic specialist.3 Reference #1: 1.Schweigert, Michael, et al. “Spotlight on Esophageal Perforation: A Multinational Study Using the Pittsburgh Esophageal Perforation Severity Scoring System.” The Journal of Thoracic and Cardiovascular Surgery, vol. 151, no. 4, 2016, pp. 1002–1011 Reference #2: 2.Gimenez, Ana, et al. “Thoracic Complications of Esophageal Disorders.” RadioGraphics, vol. 22, 2002, pg 1001-1002 Reference #3: 3.Michel L, Grillo H C, Malt R A. Operative and nonoperative management of esophageal perforations. Ann Surg 1981; vol 194: 57–63 DISCLOSURES: No relevant relationships by Meghan Brennan, source=Web Response No relevant relationships by Edward McGough, source=Web Response No relevant relationships by Miguel Rovira, source=Web Response