ATRIO-ESOPHAGEAL FISTULA: A RARE AND GRAVE COMPLICATION OF ATRIAL FIBRILLATION ABLATION

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Atrio-esophageal fistula (AEF) is an extremely rare, life-threatening complication of catheter radiofrequency ablation (RFA) which has an increasing incidence of > 50,000/year in the US. AEF commonly causes death via cerebral air embolism, massive gastrointestinal bleeding (GIB) and septic shock in 2 months post RFA. The associated mortality of AEF is > 80% and requires prompt diagnosis and intervention.(1) CASE PRESENTATION: An 80 year old female with heart failure with reduced ejection fraction and cardiomyopathy due to persistent atrial fibrillation (AF) despite prior interventions presented 18 days post convergent VATS, left atrial (LA) clip/LA appendage ligation with epicardial ablation of LA posterior wall, while on Eliquis to the ER after 1 episode of hematemesis. There was no history of PUD, melena, NSAID use or heavy alcohol use. She had tachycardia but other vitals were normal. Exam revealed dried blood in the mouth, generalized abdominal tenderness but was otherwise normal. Pantoprazole infusion was commenced. Esophagogastroduodenoscopy (EGD) revealed a large deep mid-esophageal ulcer with clot. Post EGD, she became lethargic with acute hypoxic respiratory failure and was intubated. Chest x-ray showed new lung infiltrate and she was started on Zosyn and vancomycin. CTA of the chest revealed a 2.5 cm thrombus in the posterior left atrium and air within the right atrium. Fluconazole was added and she was taken to the OR for LA repair. The next day she underwent esophagectomy and gastric tube placement, during which she developed hemorrhagic shock requiring multiple transfusions and vasopressor support. Blood cultures grew Rothia mucinolaginosus, B6-deficient streptococcus and lactobacillus and CT head showed an acute stroke. Unfortunately, she died after palliative extubation 10 days post admission. DISCUSSION: AEF following RFA has an incidence of < 0.03% and is thought to be multifactorial. Thermal injury during the ablation, results in fistulization of the esophagus into the atrium i.e. AEF, a 1-way valve, causing strokes more often than upper GIB. CTA chest is the modality of choice, as EGD increases the risk of air embolization resulting in stroke or death. Currently early surgical repair appears to have the best survival.(2) Preventative measures such as an esophageal temperature probe for real-time temperature monitoring was used in this case. However, there is a 0.016% incidence of esophageal perforation despite monitoring in 90% of patients.(3) Other strategies to prevent AEF include: reduced power titration while ablating the posterior LA wall, decrease delivery time and active esophageal cooling with saline. CONCLUSIONS: The incidence of RFA for AF is rapidly increasing for which AEF is a rare yet grave complication that uncommonly presents as hematemesis. Awareness is imperative for prompt diagnosis as without urgent surgical intervention mortality approaches 100%. Reference #1: Patricia C, Franz HM, Abel CD, et al. Atrioesophageal fistula following ablation procedures for atrial fibrillation: systematic review of case reports. Open Heart. 2015; 2(1), e000257. https://doi.org/10.1136/openhrt-2015- 000257. Reference #2: Singh SM, d’Avila A, Singh SK, et al. Clinical outcomes after repair of left atrial esophageal fistulas occurring after atrial fibrillation ablation procedures. Heart Rhythm. 2013; 10(11):1591–1597. Reference #3: Chirag RB, Saurabh K, Yu G, et al. Global Survey of Esophageal in Atrial Fibrillation: Characteristics and Outcomes of Esophageal Perforation and Fistula. JACC: Clinical Electrophysiology. 2016; 2(2):143-150. DISCLOSURES: No relevant relationships by Sahai Donaldson, source=Web Response No relevant relationships by Nisha Gandhi, source=Web Response No relevant relationships by Alexandra Gottdiener, source=Web Response No relevant relationships by Gene Otuonye, source=Web Response No relevant relationships by Dan Ran-Castillo, source=Web Response No relevant relationships by Matthew Tavares, source=Web Response