Case reportFatal course of esophageal stenting of an atrioesophageal fistula after atrial fibrillation ablation
Introduction
The development of an atrioesophageal fistula after catheter ablation of atrial fibrillation (AF) is fortunately a rare but almost always lethal complication, representing the second most frequent cause of death after pulmonary vein isolation (PVI) following cardiac tamponade (prevalence 0.04%, mortality 71%).1 Risk factors for this rare event are not yet established. The prevalence of esophageal and mediastinal injuries after PVI varies considerably in different studies and is possibly associated with the formation of an atrioesophageal fistula.2, 3, 4 Schmidt et al5 reported a very high prevalence of 47% esophageal injury diagnosed by conventional endoscopy, whereas other studies reported lower rates of esophageal changes. We were not able to show mucosal esophageal injury in a series of 29 patients, yet structural changes of the mediastinum diagnosed by endosonography occurred in 27% of the patients.2 Avoidance strategies in daily practice are diverse: monitoring the course of the esophagus using various imaging modalities, measuring the luminal esophageal temperature, reducing the power while ablating at the posterior wall of the left atrium, and performing the ablation procedure under conscious sedation rather than general anesthesia to observe pain as a surrogate for esophageal injury.6, 7, 8 Apart from this procedural management, the optimal follow-up after ablation to detect esophageal and mediastinal injuries is also unknown and may include extensive endoscopic evaluation of the esophagus.2 Despite these precautions, atrioesophageal fistulas still pose a problem, especially since establishing the correct diagnosis may be difficult. Additionally, initiation of therapy is often delayed because of late development of the fistula after ablation. Typical symptoms in the case of a fistula are fever, sepsis, and fluctuating neurological symptoms.9 Treatment options include surgery and interventional stenting of the esophagus.10, 11 Nevertheless, morbidity as well as mortality remain high.
Section snippets
Case
We report the case of a 63-year-old man suffering from highly symptomatic drug-refractory AF for 4 years who was referred to our department for PVI. Irrigated-tip catheter radiofrequency (RF) ablation (Therapy CoolPath, St. Jude Medical, St. Paul, MN; maximum 30 W, maximum 48°C) was performed as a circumferential antral isolation of the septal and lateral pulmonary veins guided by a decapolar circular mapping catheter using a 3-dimensional mapping system with the integration of a
Discussion
We report the fatal case of an atrioesophageal fistula after catheter ablation of AF. In more than 500 AF ablations thereafter, using the same ablation protocol, no other fistula occurred. The characteristic initial clinic was misdiagnosed, delaying the diagnosis and appropriate treatment. To cover the esophageal fistula opening, a fully covered self-expanding esophageal stent was used. These stents are widely used for treatment of thoracic esophageal anastomotic leaks and esophageal
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