Successful surgery for atrioesophageal fistula caused by transcatheter ablation of atrial fibrillation

Abstract

Catheter ablation (CA) is an effective and safe technique to treat atrial fibrillation; however, it can cause rare but lethal complications.1Cappato R. Calkins H. Chen S.A. Davies W. Iesaka Y. Kalman J. et al.Prevalence and causes of fatal outcome in catheter ablation of atrial fibrillation.J Am Coll Cardiol. 2009; 53: 1798-1803Abstract Full Text Full Text PDF PubMed Scopus (438) Google Scholar Atrioesophageal fistula (AEF) caused by diffusion of the ablative energy through the left atrial wall to the esophagus (because of the absence of pericardium) is lethal if not treated surgically. A 35-year-old man had a 3-year history of atrial fibrillation that had been permanent for the last 2 years. Amiodarone had proven ineffective, and an electrical cardioversion failed. Echocardiography showed the left side of his heart (left ventricular ejection fraction, 60%) to be preserved with a left atrial diameter of 27 mm. CA performed at another institution was uneventful, and the patient was discharged the next day in sinus rhythm. Thirty-eight days later, the patient had fever, chest pain, and vomiting and was urgently admitted to a peripheral hospital, where he presented a left hemiplegia and convulsive crisis. There was no early lesion observed on cerebral computed tomography (CT) scan. Blood cultures were positive for streptococcus salivarius, transthoracic echocardiography showed no evidence of endocarditis, and lumbar puncture results were unremarkable. A specific antibiotic therapy was initiated, and the patient was transferred to the University Hospital of Rangueil. Cerebral magnetic resonance imaging showed widespread ischemic changes consistent with multiple emboli, and CT scan showed cerebral, splenic, and renal emboli associated with the presence of air within the mediastinum and left atrium, suggesting an AEF (Figure 1). Because of the patient's poor condition, a silicone-covered stent was initially placed in the esophagus under radioscopy to seal off the AEF, but the stent migrated into the stomach a few hours later. Surgery was performed via a left thoracotomy because of a left pleural effusion. The left femoral vessels were accessible, and a cardiopulmonary bypass was on standby. After careful dissection, the AEF was identified and the esophagus was separated from the left atrial wall. A preventive suture was done on the atrial wall despite the absence of perforation. The esophageal perforation (Figure 2, B) was closed using adsorbable monofilament sutures. A pediculated autologous pericardial patch was then placed between the 2 sutures (Figure 2, A). A mediastinal drain was placed adjacent to the esophagus associated with a left pleural drain. Two nasogastric tubes were placed, one above the suture and one in the stomach. The patient had parenteral feeding associated with intravenous antibiotic therapy. After a water-soluble contrast CT scan that showed no esophageal leakage, drains were progressively removed and oral nutrition was reintroduced progressively 3 weeks after surgery. The patient was discharged after 5 weeks. One month later, a gastroscopy was performed to assess esophageal healing and remove the esophageal stent. Nine months later, the patient was in sinus rhythm and doing well despite his sequela left lower limb hemiparesis. AEF is a serious complication of CA for atrial fibrillation. A recent multicenter retrospective study reported 32 deaths after 45,115 procedures (0.098%). AEF was the second most frequent cause of death (n = 7; 15,6%), and overall mortality of AEF was 71.4% (n = 5/7).1Cappato R. Calkins H. Chen S.A. Davies W. Iesaka Y. Kalman J. et al.Prevalence and causes of fatal outcome in catheter ablation of atrial fibrillation.J Am Coll Cardiol. 2009; 53: 1798-1803Abstract Full Text Full Text PDF PubMed Scopus (438) Google Scholar The clinical features consist of nonspecific symptoms, such as fever, dysphagia, chest pain, or hematemesis, beginning 3 to 38 days after the procedure. Subsequently, endocarditis or pericarditis and finally multiple air emboli occur. One hypothesis about the air emboli is the capability of the esophagus to develop pressures 10 times greater than intra-atrial pressure.2Grande L. Lacima G. Ros E. Pera M. Ascaso C. Visa J. et al.Deterioration of esophageal motility with age: a manometric study of 79 healthy subjects.Am J Gastroenterol. 1999; 94: 1795-1801Crossref PubMed Scopus (104) Google Scholar Causes of death are cerebral embolism, massive gastrointestinal bleeding, and septic shock. Chest CT scan is the most useful diagnostic method and specifically shows air bubbles or a fistulous tract. Transthoracic echocardiography is useful to assess the absence of endocarditis lesion. Transesophageal echocardiography and gastroesophageal endoscopy are contraindicated considering the risk of air embolism.3Doll N. Borger M.A. Fabricius A. Stephan S. Gummert J. Mohr F.W. et al.Esophageal perforation during left atrial radiofrequency ablation: is the risk too high?.J Thorac Cardiovasc Surg. 2003; 125: 836-842Abstract Full Text Full Text PDF PubMed Scopus (276) Google Scholar Despite the report of one case of treatment with a temporary esophageal covered stent,4Bunch T.J. Nelson J. Foley T. Allison S. Crandall B.G. Osborn J.S. et al.Temporary esophageal stenting allows healing of esophageal perforations following atrial fibrillation ablation procedures.J Cardiovasc Electrophysiol. 2006; 17: 435-439Crossref PubMed Scopus (107) Google Scholar this solution failed in our case. Conventional treatment consists of urgent surgical intervention, because this is vital for all patients.3Doll N. Borger M.A. Fabricius A. Stephan S. Gummert J. Mohr F.W. et al.Esophageal perforation during left atrial radiofrequency ablation: is the risk too high?.J Thorac Cardiovasc Surg. 2003; 125: 836-842Abstract Full Text Full Text PDF PubMed Scopus (276) Google Scholar, 5Pappone C. Oral H. Santinelli V. Vicedomini G. Lang C.C. Manguso F. et al.Atrio-esophageal fistula as a complication of percutaneous transcatheter ablation of atrial fibrillation.Circulation. 2004; 109: 2724-2726Crossref PubMed Scopus (728) Google Scholar A cardiopulmonary bypass has to be ready, even if it should be reserved for salvage, because of recent neurologic lesions that are often associated. We preferred an off-pump strategy via a lateral thoracotomy, rather than a sternotomy, for an elective intracardiac repair. The choice of the left side for the approach was based on left pleural effusion draining the mediastinal infection, but a right access to the esophagus is also feasible. The esophageal repair or esophagectomy is chosen according to the local severity of necrosis and mediastinitis. A pericardial flap was easy and efficient to separate the atrial and esophageal sutures, correcting the natural pericardial defect that caused AEF after CA.