Atrio-Esophageal Fistula: A Case Series and Literature Review

Background:Percutaneous catheter radiofrequency ablation (RFA) and cryoablation of the left atrium and pulmonary vein ostia have become successful therapeutic modalities in the management of atrial fibrillation.Atrio-esophageal fistula is a rare complication.Awareness of complication risk is imperative because without prompt diagnosis and urgent surgical intervention, the outcome is often fatal.We present 3 cases of atrio-esophageal fistula following percutaneous catheter radiofrequency ablation (RFA). Case Reports:Case 1: A 72-year old white male presented 27 days after percutaneous RFA for atrial fibrillation with fever, altered mental status, and melena.Esophagogastroduodenoscopy (EGD) revealed a 1-cm defect in the mid-esophagus.Upon thoracotomy, severe hemorrhage ensued from a concomitant injury to the left atrium.Multiple attempts to repair the left atrial perforation were unsuccessful and the patient died.Case 2: A 71-year old white male presented 29 days after percutaneous RFA for atrial fibrillation with fever and tonic-clonic seizure.Recognition of possible atrio-esophageal fistula was considered and confirmed on thoracotomy.Surgical fixation of the left atria and esophagus were performed.The patient survived and was discharged to a skilled care facility.Case 3: A 75-year old white male presented 24 days after percutaneous RFA for atrial fibrillation with chest pain.An echocardiogram revealed a large pericardial effusion and pericardiocentesis was performed.Despite aggressive measures, the patient died.The autopsy demonstrated a communicating esophageal fistula with the right pulmonary vein. Conclusions:Clinicians tending to patients who have recently undergone atrial ablation need to be aware of atrio-esophageal fistula as a rare but highly fatal complication.