Atrioesophageal fistula: A risk of atrial fibrillation ablation

Learning Objectives: Atrial-Fibrillation (AFib) affects 3-6 million Americans. Preferred management is rate-control with anticoagulation. Rhythm-control can be used for symptomatic AFib with some support for atrial ablation as a safe alternative, especially to avoid antiarrhythmic adverse effects. There is an observed 3% complication rate associated with ablation. The most severe complication, Atrioesophageal Fistula (AEF), occurs in less than 0.1% of patients. Despite the rare occurrence, it carries a high rate of mortality. Methods: 52-year-old male with history of AFib on rivaroxaban and metoprolol, now 3 weeks post radiofrequency ablation, presented with ripping chest pain. He was febrile and tachycardic with leukocytosis. CT angiography was negative for concern of aortic dissection. He had a seizure in the ED prompting antibiotic treatment of suspected CNS infection. Blood cultures grew S. mitis, S. salvarius and Neisseria species. Subsequent development of left extremity weakness prompted CNS imaging which revealed multiple acute infarcts. He was transferred to a tertiary center for escalation of care. On ICU arrival, repeat CT head confirmed embolic infarcts with new hemorrhage. Review of outside CT chest showed extra-esophageal gas posterior to the left atrium concerning for AEF. Cardiothoracic surgery performed CT esophogram confirming gas but no signs of AEF. Endoscopy did not reveal esophageal perforation. TEE ruled out endocarditis, but found a small ASD. AEF was thought unlikely and an IVC filter was placed. Later while eating, the patient had acute loss of consciousness requiring intubation. CT head without contrast showed new embolic infarcts and hemorrhages. Given recurrence of fever and bacteremia, CT body was performed showing air in the left atrium supporting previously suspected AEF. Neurologically devastated and a poor surgical candidate, he was made comfort care and passed. Results: Patients developing AEF usually present 2-60 days after ablation. Most common symptoms are fever, neurological deficits, bleeding and chest pain. Fistulas are often one-way causing embolism more often than bleed. CT is the test of choice but only 75% sensitive initially and 85% on repeat. Endoscopy and TEE are relatively contraindicated. Surgery is the preferred treatment with 34% mortality versus 64% with stenting and almost 100% with medical management. AEF are extremely difficult to confirm and often herald death, but with high suspicion and rapid intervention meaningful survival is possible