Timothy Ball, MD1, Vishal Kaila, MD2, Jay Franklin, MD1, Manish Assar, MD1, Beth Frost, DO3, Jeffrey Barnard, MD4, Rajeev Jain, MD5
1Baylor University Medical Center, Dallas, TX; 2Texas Health Presbyterian, Dallas, TX; 3Maricopa Integrated Health System, Phoenix, AZ; 4University of Texas Southwestern Medical Center, Dallas, TX; 5Texas Digestive Disease Consultants, PA, Dallas, TX
Introduction: Atrial fibrillation is the most common cardiac arrhythmia globally, with an estimated prevalence of 33.5 million persons. Over the past 20 years, catheter ablation for atrial fibrillation has grown in acceptance and is now a first-line treatment option for patients with symptomatic paroxysmal atrial fibrillation. Atrioesophegeal fistula (AEF) is a rare but often fatal complication associated with atrial fibrillation ablation.
Case Description/Methods: A 73-year-old woman who underwent radiofrequency ablation for atrial fibrillation 7 weeks prior to presentation to the hospital presented with right-hand weakness, numbness, and ataxia. Initial laboratory evaluation was remarkable for hemoglobin 9.2 g/dL(13.0-17.0 g/dL). Initially, a head computerized tomography (CT) was unremarkable but a subsequent magnetic resonance imaging study demonstrated a right cerebellar stroke. Tissue plasminogen was not prescribed. Transthoracic echocardiogram showed normal left ventricular systolic function, with dilated atria. Later on the day of admission, she developed hematemesis. On day 2 of her admission, she underwent esophagogastroduodenoscopy (EGD) and was found to have a large esophageal defect with thrombus and active bleeding (See Figure 1 and 2). Her clinical status declined quickly and she was taken emergently to the operating room. Unfortunately, despite maximal supportive care, she died prior to surgery. Autopsy revealed an atrioesophageal fistula involving the middle 1/3 of the esophagus and the posterior wall of the left atrium adjacent to the left pulmonary veins. The defects measured 1.5 x 1.0 cm on the esophageal portion and 1 cm x 1 cm on the atrial aspect (See Figure 3). The stomach contained 910cc of both liquid and clotted blood.
Discussion: AEF typically occur 20±12 days post-ablation, ranging from 2 to 60 days. AEF has been reported in surgical RFA, percutaneous RFA, and cryoballoon ablation for atrial fibrillation. CT of the chest with intravenous contrast can show pneumomediastinum, pericardial effusion, and communication between the atrium and esophagus. EGD and transesophageal echocardiogram are not recommended if AEF is suspected, as air insufflation during either procedure may lead to massive air embolization and worsening bleeding. Following the diagnosis of AEF, early surgical intervention is critical as the mortality rate without intervention is 100%. AEF is a rare but often fatal complication of catheter ablation for atrial fibrillation. Untreated, the mortality rate of AEF is 100%.
Citation: Timothy Ball, MD; Vishal Kaila, MD; Jay Franklin, MD; Manish Assar, MD; Beth Frost, DO; Jeffrey Barnard, MD; Rajeev Jain, MD. P0430 - ATRIOESOPHEGEAL FISTULA, A RARE BUT DEVASTATING CAUSE OF UPPER GASTROINTENTINAL BLEEDING. Program No. P0430. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.