Left Atrial–Esophageal Fistula After Pulmonary Vein Isolation
2007; Lippincott Williams & Wilkins; Volume: 115; Issue: 17 Linguagem: Inglês
10.1161/circulationaha.106.680181
ISSN1524-4539
AutoresAndré d’Ávila, Leon M. Ptaszek, Paul B. Yu, Jennifer Walker, Cameron D. Wright, Peter A. Noseworthy, A. Myers, Marwan M. Refaat, Jeremy N. Ruskin,
Tópico(s)Cardiac Arrhythmias and Treatments
ResumoHomeCirculationVol. 115, No. 17Left Atrial–Esophageal Fistula After Pulmonary Vein Isolation Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBLeft Atrial–Esophageal Fistula After Pulmonary Vein IsolationA Cautionary Tale Andre D'Avila, MD, Leon M. Ptaszek, MD, PhD, Paul B. Yu, MD, PhD, Jennifer D. Walker, MD, Cameron Wright, MD, Peter A. Noseworthy, MD, Andrea Myers, MD, PhD, Marwan Refaat, MD and Jeremy N. Ruskin, MD Andre D'AvilaAndre D'Avila From the Cardiac Arrhythmia Service (A.D., J.N.R.), Cardiology Division (L.M.P., P.B.Y.), Department of Cardiac Surgery (J.D.W.), Department of Thoracic Surgery (C.W.), and Department of Internal Medicine (P.A.N., A.M., M.R.), Massachusetts General Hospital, Boston, Mass. , Leon M. PtaszekLeon M. Ptaszek From the Cardiac Arrhythmia Service (A.D., J.N.R.), Cardiology Division (L.M.P., P.B.Y.), Department of Cardiac Surgery (J.D.W.), Department of Thoracic Surgery (C.W.), and Department of Internal Medicine (P.A.N., A.M., M.R.), Massachusetts General Hospital, Boston, Mass. , Paul B. YuPaul B. Yu From the Cardiac Arrhythmia Service (A.D., J.N.R.), Cardiology Division (L.M.P., P.B.Y.), Department of Cardiac Surgery (J.D.W.), Department of Thoracic Surgery (C.W.), and Department of Internal Medicine (P.A.N., A.M., M.R.), Massachusetts General Hospital, Boston, Mass. , Jennifer D. WalkerJennifer D. Walker From the Cardiac Arrhythmia Service (A.D., J.N.R.), Cardiology Division (L.M.P., P.B.Y.), Department of Cardiac Surgery (J.D.W.), Department of Thoracic Surgery (C.W.), and Department of Internal Medicine (P.A.N., A.M., M.R.), Massachusetts General Hospital, Boston, Mass. , Cameron WrightCameron Wright From the Cardiac Arrhythmia Service (A.D., J.N.R.), Cardiology Division (L.M.P., P.B.Y.), Department of Cardiac Surgery (J.D.W.), Department of Thoracic Surgery (C.W.), and Department of Internal Medicine (P.A.N., A.M., M.R.), Massachusetts General Hospital, Boston, Mass. , Peter A. NoseworthyPeter A. Noseworthy From the Cardiac Arrhythmia Service (A.D., J.N.R.), Cardiology Division (L.M.P., P.B.Y.), Department of Cardiac Surgery (J.D.W.), Department of Thoracic Surgery (C.W.), and Department of Internal Medicine (P.A.N., A.M., M.R.), Massachusetts General Hospital, Boston, Mass. , Andrea MyersAndrea Myers From the Cardiac Arrhythmia Service (A.D., J.N.R.), Cardiology Division (L.M.P., P.B.Y.), Department of Cardiac Surgery (J.D.W.), Department of Thoracic Surgery (C.W.), and Department of Internal Medicine (P.A.N., A.M., M.R.), Massachusetts General Hospital, Boston, Mass. , Marwan RefaatMarwan Refaat From the Cardiac Arrhythmia Service (A.D., J.N.R.), Cardiology Division (L.M.P., P.B.Y.), Department of Cardiac Surgery (J.D.W.), Department of Thoracic Surgery (C.W.), and Department of Internal Medicine (P.A.N., A.M., M.R.), Massachusetts General Hospital, Boston, Mass. and Jeremy N. RuskinJeremy N. Ruskin From the Cardiac Arrhythmia Service (A.D., J.N.R.), Cardiology Division (L.M.P., P.B.Y.), Department of Cardiac Surgery (J.D.W.), Department of Thoracic Surgery (C.W.), and Department of Internal Medicine (P.A.N., A.M., M.R.), Massachusetts General Hospital, Boston, Mass. Originally published1 May 2007https://doi.org/10.1161/CIRCULATIONAHA.106.680181Circulation. 2007;115:e432–e433A 56-year-old man presented with a 3-day history of progressive epigastric burning, dysphagia, and tactile fever. These symptoms started approximately 4 weeks after an uncomplicated pulmonary vein isolation procedure for atrial fibrillation had been performed at an outside facility. At the time of presentation, the patient was found to be febrile, and blood cultures were positive for Streptococcus viridans growth. Appropriate antibiotic therapy was started at that time. Chest x-ray did not reveal any abnormal findings. Because endocarditis was suspected, transthoracic and transesophageal echocardiograms were performed, but no valvular abnormalities were found. Subsequently, he developed right arm and right leg weakness and a naming deficit associated with anomia, acalculia, and agraphia. He was then transferred to our hospital for further evaluation.At the time of transfer, the patient was still febrile, with a temperature of 39°C. Cardiac examination did not reveal any noteworthy abnormalities, but the patient was noted to have left–right confusion, right-sided neglect, and dense aphasia and anomia. Motor examination revealed weakness in the right arm and right leg. These changes were considered to be consistent with stroke affecting the left hemisphere, including the left parietal, perisylvian, and frontal regions. Brain magnetic resonance imaging revealed multiple subacute embolic events (Figure, C). Given his recent history of a pulmonary vein ablation procedure, a cardiac source for these embolization events was considered likely. A chest computed tomography scan revealed air interposed between the left superior pulmonary vein, within the left atrial appendage (Figure, A), and in the left ventricle (Figure, B). The presence of air in the atrium and the growth of oral flora in blood cultures both suggested the presence of a left atrial–esophageal fistula. The patient was taken to the operating room for repair of the presumed fistula. During surgery, the esophagus was noted to be densely adherent to the parietal pericardium and the left pulmonary vein (Figure, D). The atrial lesion was closed with a single mattress suture and pericardial pledgets, the atrium was punctured with a needle, and 3 mL of air was aspirated. The esophageal lesion was buttressed with an intercostal muscle flap. Intraoperative ultrasound showed no air in the atrium. The patient's neurological defects were significantly improved after surgery, and the patient was discharged. Download figureDownload PowerPointA, Transverse section of chest computed tomography scan, revealing air in left atrial appendage and left superior pulmonary artery. B, Transverse section of chest computed tomography scan, revealing air in the left ventricle. C, Brain magnetic resonance imaging, revealing embolic events throughout both hemispheres. D, Intraoperative photograph, revealing affected area of esophagus, including abscess (arrow).Left atrial–esophageal fistula is not a common complication of pulmonary vein isolation, but it is fatal in most reported cases.1 Fistula formation is the result of thermal injury of esophageal tissues from application of radiofrequency energy to the immediately adjacent left atrium.2 It is noteworthy that in this patient, the pulmonary vein isolation procedure was standard according to currently accepted criteria: a cooling catheter was used during the ablation procedure, which involved ablation of a right atrial flutter circuit and pulmonary vein isolation in the left atrium.Symptoms related to left atrial–esophageal fistula typically emerge 1 to 5 weeks after treatment. Fever, malaise, dysphagia, and neurological symptoms in patients with recent catheter ablation of atrial fibrillation should raise suspicion for fistula formation. Endoscopy and transesophageal echocardiography should not be performed, because further embolism or catastrophic bleeding may be caused by the attendant elevation in esophageal pressure. A computed tomography scan of the chest may reveal mediastinal or intravascular air and should be the preferred diagnostic test. The general practitioner should be aware of this complication because it is life threatening, and the early presenting symptoms are frequently nonspecific. Immediate surgical repair is indicated because spontaneous resolution of a left atrial–esophageal fistula has not been reported.DisclosuresNone.FootnotesCorrespondence to Andre D'Avila, MD, Cardiac Arrhythmia Service, Massachusetts General Hospital, 55 Fruit Street, GRB 109, Boston, MA 02114. E-mail [email protected]References1 Cummings JE, Schweikert RA, Saliba WI, Burkhardt JD, Kilikaslan F, Saad E, Natale A. Brief communication: atrial-esophageal fistulas after radiofrequency ablation. Ann Intern Med. 2006; 144: 572–574.CrossrefMedlineGoogle Scholar2 Cury RC, Abbara S, Schmidt S, Malchano ZJ, Neuzil P, Weichet J, Ferencik M, Hoffmann U, Ruskin JN, Brady TJ, Reddy VY. Relationship of the esophagus and aorta to the left atrium and pulmonary veins: Implications for catheter ablation of atrial fibrillation. Heart Rhythm. 2005; 2: 1317–1323.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Pasteur-Rousseau A and Sebag F (2020) Scanner cardiaque : intérêt dans le bilan des douleurs thoraciques, dans le dépistage cardiovasculaire et dans le bilan pré-ablation de fibrillation auriculaire, Annales de Cardiologie et d'Angéiologie, 10.1016/j.ancard.2020.09.028, 69:5, (276-288), Online publication date: 1-Nov-2020. Walters T, Ellims A and Kalman J (2019) Intracardiac Echocardiography, Computed Cardiac Tomography, and Magnetic Resonance Imaging for Guiding Mapping and Ablation Catheter Ablation of Cardiac Arrhythmias, 10.1016/B978-0-323-52992-1.00009-0, (126-142.e6), . Buch E, Khakpour H and Shivkumar K (2019) Guiding Lesion Formation During Radiofrequency Catheter Ablation Catheter Ablation of Cardiac Arrhythmias, 10.1016/B978-0-323-52992-1.00002-8, (18-26.e3), . Jehaludi A, Heist E, Giveans M and Anand R (2018) Retrospective review of 65 atrioesophageal fistulas post atrial fibrillation ablation, Indian Pacing and Electrophysiology Journal, 10.1016/j.ipej.2018.02.002, 18:3, (100-107), Online publication date: 1-May-2018. Zhou B, Cen X, Qian L, Pang J, Zou H and Ding Y (2016) Treatment strategy for treating atrial-esophageal fistula, Medicine, 10.1097/MD.0000000000005134, 95:43, (e5134), Online publication date: 1-Oct-2016. Steven D, van den Bruck J, Plenge T, Lüker J and Sultan A (2015) Katheterablation und die KomplikationenCatheter ablation and the complications, Herzschrittmachertherapie + Elektrophysiologie, 10.1007/s00399-015-0402-6, 26:4, (338-343), Online publication date: 1-Dec-2015. Singh S, d'Avila A, Singh S, Stelzer P, Saad E, Skanes A, Aryana A, Chinitz J, Kulina R, Miller M and Reddy V (2013) Clinical outcomes after repair of left atrial esophageal fistulas occurring after atrial fibrillation ablation procedures, Heart Rhythm, 10.1016/j.hrthm.2013.08.012, 10:11, (1591-1597), Online publication date: 1-Nov-2013. Contreras-Valdes F, Heist E, Danik S, Barrett C, Blendea D, Brugge W, Ptaszek L, Ruskin J and Mansour M (2011) Severity of esophageal injury predicts time to healing after radiofrequency catheter ablation for atrial fibrillation, Heart Rhythm, 10.1016/j.hrthm.2011.07.022, 8:12, (1862-1868), Online publication date: 1-Dec-2011. DI BIASE L, DODIG M, SALIBA W, SIU A, SANTISI J, POE S, SANAKA M, UPCHURCH B, VARGO J and NATALE A (2010) Capsule Endoscopy in Examination of Esophagus for Lesions After Radiofrequency Catheter Ablation: A Potential Tool to Select Patients With Increased Risk of Complications, Journal of Cardiovascular Electrophysiology, 10.1111/j.1540-8167.2010.01732.x, Online publication date: 1-Feb-2010. Katzka D (2010) Esophageal Disorders Caused by Medications, Trauma, and Infection Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 10.1016/B978-1-4160-6189-2.00045-7, (735-743.e4), . LEMERY R (2010) Left Atrial Anatomy, Energy Delivery and Esophageal Complications Associated With Ablation of Atrial Fibrillation, Journal of Cardiovascular Electrophysiology, 10.1111/j.1540-8167.2010.01752.x, Online publication date: 1-Mar-2010. Stevenson W and Saltzman J (2009) Gastroesophageal reflux and atrial–esophageal fistula, Heart Rhythm, 10.1016/j.hrthm.2009.07.023, 6:10, (1463-1464), Online publication date: 1-Oct-2009. Abu-Shaban K and Kelsch R (2015) Atrio-oesophageal fistula Radiopaedia.org, 10.53347/rID-41801 May 1, 2007Vol 115, Issue 17 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.106.680181PMID: 17470703 Originally publishedMay 1, 2007 PDF download Advertisement SubjectsCardiovascular SurgeryCatheter Ablation and Implantable Cardioverter-DefibrillatorCerebrovascular Disease/StrokeComputerized Tomography (CT)Imaging
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