Atrial Esophageal Fistula Secondary to Ablation for Atrial Fibrillation

This article describes 2 patients who presented to our institution with left atrial esophageal fistula after atrial fibrillation ablation; it also compares our experience with other atrial esophageal fistula cases reported in the literature. We performed a retrospective review of 2 patients who presented to our hospital between July 2015 and September 2015 with atrial esophageal fistula. Patient A, a 57-year-old man, presented 31 days postablation with a fever and right-sided weakness. A chest computed tomography showed gas in the left atrium and esophagus; an echocardiogram confirmed the diagnosis of atrial esophageal fistula. The patient subsequently underwent a left thoracotomy. Postoperative recovery was poor and included significant coagulopathy, sepsis, cardiogenic shock, and multisystem organ failure. The patient died on postoperative day 28. Patient B, a 77-year-old man, presented 21 days post-atrial fibrillation ablation with left-arm weakness and altered mental status. An esophagram was performed and showed no evidence of an esophageal perforation. Because of positive cultures and worsening altered mental status, the patient underwent a head computed tomography, which showed pneumocephalus, leading to our suspicion of the atrial esophageal fistula. A follow-up chest computed tomography confirmed the atrial esophageal fistula. Treatment included an esophagectomy and repair of the atrium. Unfortunately, the atrial esophageal fistula closure dehisced, and the patient developed acute respiratory failure and cardiac tamponade, which led to cardiopulmonary arrest, and the patient died on postoperative day 10. Based on our experience, and the literature, we recommend that a chest computed tomography be immediately performed on patients presenting with the described symptoms after a recent atrial fibrillation ablation.

Atrioesophageal Fistula after Ablation for Atrial Fibrillation

BACKGROUND

Atrioesophageal fistula (AEF) is a rare and highly fatal complication of ablation procedures for atrial fibrillation. We report a diagnostically challenging case of AEF that highlights the unfortunate outcome that can be expected when this condition is not promptly diagnosed and managed accordingly. The varied clinical presentations are reviewed and recommended diagnostic and management approaches are presented.

CASE REPORT

A 79-year-old female who was 5 weeks post-ablation presented to a community emergency department with chest pain and a transient episode of left-arm weakness. Troponin was mildly elevated, but other investigations, including thoracic and head computed tomography (CT) were normal. During the course of the next few days in hospital, the diagnosis of AEF became apparent, as the patient developed a fever and recurrent episodes of neurologic deficits along with blood cultures that yielded upper gastrointestinal flora. The patient was urgently transferred to a tertiary center where repeat thoracic CT confirmed the diagnosis, but she succumbed to an intracranial bleed before definitive surgical management could be performed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case is presented to increase awareness among emergency physicians of this fatal condition that is increasing in incidence as ablation procedures become more mainstream. The diagnosis can be challenging, given that presenting symptoms are often variable and nonspecific. To complicate matters further, performing certain diagnostic tests and interventions can prove fatal in this particular patient population. Survival in these unfortunate cases is highly dependent on initiating a prompt and appropriate diagnostic workup, followed by rapid surgical intervention.

Feasibility Study on Cardiac Arrhythmia Ablation Using High-Energy Heavy Ion Beams

High-energy ion beams are successfully used in cancer therapy and precisely deliver high doses of ionizing radiation to small deep-seated target volumes. A similar noninvasive treatment modality for cardiac arrhythmias was tested here. This study used high-energy carbon ions for ablation of cardiac tissue in pigs. Doses of 25, 40, and 55 Gy were applied in forced-breath-hold to the atrioventricular junction, left atrial pulmonary vein junction, and freewall left ventricle of intact animals. Procedural success was tracked by (1.) in-beam positron-emission tomography (PET) imaging; (2.) intracardiac voltage mapping with visible lesion on ultrasound; (3.) lesion outcomes in pathohistolgy. High doses (40–55 Gy) caused slowing and interruption of cardiac impulse propagation. Target fibrosis was the main mediator of the ablation effect. In irradiated tissue, apoptosis was present after 3, but not 6 months. Our study shows feasibility to use high-energy ion beams for creation of cardiac lesions that chronically interrupt cardiac conduction.

Medical devices: from licensing to coverage. highlights from Argentina, Brazil, Colombia and Mexico

OBJECTIVES

To describe and compare the requirements for medical devices licensing and reimbursement in four Latin-American countries.

METHODS

We conducted a literature search in major databases, and generic Internet engines, and interviewed key informants.

RESULTS

We included all publications describing regulation and/or coverage and enriched them with key informant's interviews. We found that licensing processes are similar. The decision-making process for coverage is not formally different than the one used for drugs. Although countries differ, Brazil, Colombia and Mexico have an explicit process informed by Health Technology Assessment. In general, coverage policies are defined for procedures and don´t specify device brand or model, and for that reason they may reimburse without explicit one by one device evaluation.

CONCLUSIONS

The process for licensing and reimbursement is broadly similar but less stringent than that for drugs. It allows the adoption of medical devices without individual comprehensive assessment.

Complications associated with radiofrequency ablation of pulmonary veins

OBJECTIVE

Radiofrequency ablation is an efficacious alternative in patients with symptomatic atrial fibrillation who do not respond to or are intolerant to at least one class I or class III antiarrhythmic drug. Although radiofrequency ablation is a safe procedure, complications can occur. Depending on the location, these complications can be classified into those that affect the pulmonary veins themselves, cardiac complications, extracardiac intrathoracic complications, remote complications, and those that result from vascular access. The most common complications are hematomas, arteriovenous fistulas, and pseudoaneurysms at the puncture site. Some complications are benign and transient, such as gastroparesis or diaphragmatic elevation, whereas others are potentially fatal, such as cardiac tamponade.

CONCLUSION

Radiologists must be familiar with the complications that can occur secondary to pulmonary vein ablation to ensure early diagnosis and treatment.

Treatment strategy for treating atrial-esophageal fistula: esophageal stenting or surgical repair?: A case report and literature review

INTRODUCTION

Atrial-esophageal fistula (AEF) is a rare severe disease, which may be associated with radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) or intraoperative radiofrequency ablation of atrial fibrillation (IRAAF).

CLINICAL FINDINGS

We reported a case of a 67-year-old man with AEF following RFCA of AF, who treated with esophageal stenting and surgical repair.

OUTCOMES

He was attacked by out-of-control sepsis and infectious shock after surgery and died.

LITERATURE REVIEW

We analyzed 57 relevant articles about AEF from 2003 to 2015 by searching PubMed database. According literatures, the most common symptoms were fever, rigor, sepsis, and neurologic symptoms. Chest computer tomography (CT) and contrast enhanced CT may be the reliable noninvasive diagnosis methods because of high sensitive for AEF.

CONCLUSION

Make a definition diagnosis in time with early primary surgical repair may save their lives. Conservative treatment or esophageal stenting alone may not be a better choice for AEF patients.

Gastrointestinal complications associated with catheter ablation for atrial fibrillation

Atrial fibrillation is the most common arrhythmia in the United States. With the ageing population, the incidence and prevalence of atrial fibrillation are on the rise. Catheter ablation of atrial fibrillation is a widely accepted treatment modality in patients with drug refractory symptomatic paroxysmal or persistent atrial fibrillation. The close proximity to the left atrium posterior wall makes the thermosensitive esophagus a potential site of injury during catheter ablation of AF leading to various gastrointestinal complications. The major gastrointestinal complications associated with catheter ablation include atrioesophageal fistula, gastroparesis, esophageal thermal lesions and esophageal ulcers. Multiple studies, case reports and series have described these complications with various catheter ablation techniques such as radiofrequency, cryoenergy and high frequency focused ultrasound energy ablation. This review addresses the gastrointestinal complications after AF ablation procedures and aims to provide the clinicians with an overview of clinical presentation, etiology, pathogenesis, prevention and management of these conditions.

Atrio-oesophageal fistula: dismal outcome of a rare complication with no common solution

Atrio-oesophageal fistula caused by diffusion of ablative energy through the left atrial wall to the oesophagus is a lethal complication. A high level of suspicion, rapid diagnosis and early correction are of crucial importance. In this review, we highlight the key points that will aid in the thought processes and provide guidance in the prevention, early diagnosis and management to reduce complications and improve outcome when atrio-oesophageal fistula is suspected.

Management of Atrio-Esophageal Fistula Following Left Atrial Ablation

Currently, no guidelines have been established for the treatment of atrio-esophageal fistula (AEF) secondary to left atrial ablation therapy. After comprehensive literature review, we aim to make suggestions on the management of this complex complication and also present a case series. We performed a review of the existing literature on AEF in the setting of atrial ablation. Using keywords atrial fibrillation, atrial ablation, fistula formation, atrio-esophageal fistula, complications, interventions, and prognosis, a search was made using the medical databases PUBMED and MEDLINE for reports in English from 2000 to April 2015. A statistical analysis was performed to compare the three different intervention arms: medical management, stent placement and surgical intervention. The results of our systematic review confirm the high mortality rate associated with AEF following left atrial ablation and the necessity to diagnose atrio-esophageal injury in a timely manner. The mortality rates of this complication are 96% with medical management alone, 100% with stent placement, and 33 % with surgical intervention. Atrio-esophageal injury and subsequent AEF is an infrequent but potentially fatal complication of atrial ablation. Early, prompt, and definitive surgical intervention is the treatment of choice.