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

Acquired atrioesophageal fistula: Need it be lethal? Sizing up the problem, diagnostic modalities, and best management

BACKGROUND AND AIM OF THE STUDY

An atrioesophageal fistula is a devastating complication of ablation for atrial fibrillation. For the surgeon facing this dreaded complication, it may be a 'once in a lifetime' case. This review aims to describe the clinical problem and evaluate the outcome of different surgical techniques to start guiding cardiothoracic surgeons toward those which offer the best chance of survival.

METHODS

An electronic search retrieved 125 articles containing 195 cases of atrioesophageal fistula secondary to atrial fibrillation ablation. Reports of pericardio-esophageal or mediastino-esophageal fistula were excluded.

RESULTS

The median age was 61 and 143 (73%) cases occurred in males. Fever (n = 147; 75%) and neurological dysfunction (n = 151; 77%) were the most common symptoms. The median time from ablation to symptom onset was 21 days (interquartile range: 12-28). The most sensitive thoracic imaging modality was computed tomography (n = 135/153; 90%). Immediate deterioration occurred during 11/58 (19%) oesophago-gastro-duodenoscopies. Mortality was lower in patients who had surgery (39%) compared with endoscopic intervention (94%) or conservative management (97%). Patients who had atrial repair combined with esophageal repair or oesophagectomy were more likely to survive than those who had atrial repair alone (OR 6.97; p < .001). Isolation of the esophageal aspect of the fistula conferred an additional survival benefit (OR 5.85; p = .02).

CONCLUSIONS

Fever, neurological symptoms, and chest pain in the context of recent ablation should prompt immediate evaluation. Urgent CT thorax should be arranged and repeated if initially unremarkable. Esophageal instrumentation should be avoided due to the risk of catastrophic air embolism or massive hemorrhage. The best way forward is emergency surgical repair; the combination which offers the best survival benefit is atrial repair combined with esophageal surgery and isolation of the esophageal aspect of the fistula.

Esophageal Findings in the Setting of a Novel Preventive Strategy to Avoid Thermal Lesions during Hybrid Thoracoscopic Radiofrequency Ablation for Atrial Fibrillation

Purpose The development of an atrio-esophageal fistula, a rare yet potentially lethal complication of ablation for atrial fibrillation, could be related to direct tissue heat transfer during and immediately after the ablation. We therefore studied the postoperative esophageal findings by esophagogastroduodenoscopy in patients that underwent a hybrid ablation procedure using a novel preventive strategy to avoid thermal lesions. Methods Thirty-four patients (28 males; 65 years ± 9 years) were retrospectively included. All underwent a hybrid ablation in our center between April 2015 and November 2019 and agreed to an esophagogastroduodenoscopy within 0–14 days (mean: 5 days) following the ablation. To reduce the incidence of thermal lesions three procedural preventive strategies were introduced: (i) videoscopic intrathoracic transesophageal echocardiographic probe visualization to understand the relationship between posterior left atrial wall and esophagus, with probe retraction before ablation; (ii) lifting the cardiac tissue away from the esophagus during energy application; and (iii) a 30-s cool-off period after energy delivery with irrigation of the device, the ablated tissue, and the surrounding tissues. Results No esophageal thermal lesions were observed. One third of patients were diagnosed with incidental esophageal findings unrelated to the ablation procedure (11; 32.4%). Conclusion Novel preventive strategies by visualization and by avoiding contact between the ablation catheter or ablated tissue and the pericardium, seems to eliminate the potential risk of esophageal thermal lesions in the setting of hybrid ablation. Since one third of patients had preexisting esophageal disease, a more comprehensive pre-operative screening could be important to reduce the risk.

Salvage Esophagectomy After Atrioesophageal Repair

Atrioesophageal fistula is a rare but highly morbid complication after endovascular ablation for atrial fibrillation. We report the case of a 63-year-old man with an atrioesophageal fistula after ablation who presented with neurologic symptoms and underwent emergent repair. He subsequently sustained a leak from the esophageal repair requiring emergent esophagectomy with end-esophagostomy. After several months, the patient underwent re-establishment of gastrointestinal continuity via retrosternal gastric conduit reconstruction.

Gastrointestinal and liver diseases and atrial fibrillation: a review of the literature

Atrial fibrillation (AF) is the most common arrhythmia worldwide and is associated with significant morbidity and mortality. A number of risk factors have been associated with AF, though few studies have explored the association between gastrointestinal and liver diseases and AF. Additionally, AF and treatment for AF may predispose to gastrointestinal and liver diseases. We review the current literature on the bidirectional associations between gastrointestinal and liver diseases and AF. We highlight the gaps in knowledge and areas requiring future investigation.

Iatrogenic atrio-esophageal fistula following a video-assisted thoracoscopic maze procedure: Is esophageal instrumentation justified even when the diagnosis is equivocal?

A 74-year-old female underwent an uneventful bilateral thoracoscopic maze procedure for persistent atrial fibrillation with continuous transesophageal echocardiographic (TEE) guidance. She presented six weeks later with persistent fever and focal neurological signs. Computed tomography of the thorax revealed air in the posterior LA, raising suspicion for an abscess versus an atrioesophageal fistula (AEF). Before undergoing an exploratory median sternotomy, an esophagogastroduodenoscopy (EGD) was performed by the surgeon to check for any esophageal pathology. This however, resulted in sudden hemodynamic compromise that required intensive treatment with vasopressors and inotropes. In this case-report, we review the various intraoperative risk factors associated with the development of AEF during cardiac ablation procedures as well as the potential hazards of esophageal instrumentation with TEE, naso- or oro- gastric devices, and/or an EGD when an AEF is suspected.

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.