Atrio-Esophageal Fistula as a Complication of Percutaneous Transcatheter Ablation of Atrial Fibrillation

TLDR

Radiofrequency ablation for atrial fibrillation is widely used, but atrio‑esophageal fistulas can develop after posterior left atrial wall ablation, as illustrated by two patients who presented with endocarditis‑like symptoms 3–5 days post‑procedure. The authors propose that using lower power and temperature settings during posterior left atrial wall ablation may prevent atrio‑esophageal fistula formation. Clinicians should exclude atrio‑esophageal fistula in patients with endocarditis‑like symptoms after ablation and perform urgent cardiac surgery if confirmed, while lower power/temperature settings may reduce risk. Both patients developed fistulas, rapidly deteriorated with multiple embolic events, and one survived after emergency surgery while the other died.

Abstract

Radiofrequency ablation for atrial fibrillation is becoming widely practiced.Two patients undergoing circumferential pulmonary vein ablation for atrial fibrillation in different centers developed symptoms compatible with endocarditis 3 to 5 days after the procedure. Their clinical condition deteriorated rapidly, and both suffered multiple gaseous and/or septic embolic events causing cerebral and myocardial damage. One patient survived after emergency cardiac and esophageal surgery; the other died of extensive systemic embolization. An atrio-esophageal fistula was identified in both patients.Atrio-esophageal fistulas can occur after catheter ablation in the posterior wall of the left atrium. This diagnosis should be excluded in any patient with symptoms or signs of endocarditis after left atrial ablation, and expeditious cardiac surgery is critical if the diagnosis is confirmed. Lower power and temperature settings for applications of radiofrequency energy along the posterior left atrial wall may prevent further cases of fistula formation.