No abstract

Atrioesophageal fistula (AEF) is a rare but devastating complication of radiofrequency ablation (RFCA) for atrial fibrillation (AF) and is associated with high mortality rates.Whereas most cases of AEF are treated by emergency surgical interventions, we report a case of paroxysmal AF with AEF after combined therapy of catheter ablation and percutaneous left atrial appendage closure (LAAC), which was treated successfuly without major surgery or esophageal stenting. He was presented 18 days after the procedure, suffering chest pain, fever, and a transient loss of consciousness. Computed tomography (CT) of the chest disclosed a small accumulation of air in the region of the left atrium adjacent to the esophagus, suggesting AEF. Supported by early aggressive antibiotic therapy, pericardial drainage and a fasting state with adequate parenteral nutrition, resulted in improvement of his condition with no recurrence of symptoms.Subsequent chest CT scans confirmed disappearance of the leaked air and the patient was discharged home 28 days after admission with no neurological compromise. Early detection, rapid treatment and constant awareness of potential fatal consequences are prerequisites for successful treatment of this complication and prevention of fatal outcome.

Background: The role of transthoracic echocardiography (TTE) in assessing diastolic function in patients with atrial fibrillation (AF) has not been well characterized. We sought to determine the utility of TTE in detecting elevated left atrial pressure (LAP) in patients with chronic non-valvular AF using directly measured LAP as the reference standard.Methods: We prospectively studied 35 patients with persistent AF and preserved left ventricular ejection fraction who underwent radiofrequency ablation. LAP was measured in conjunction with trans-septal puncture at the time of catheter ablation. TTE was performed in 24 hours before ablation, peak velocity of early mitral diastolic inflow velocity (E) and mitral annular velocity (e’) were recorded.Results: E and E/e’ correlated well with mean LAP (E, r=0.560, p<0.001; E/e’avg, r=0.456, p=0.005). Using receiver operating characteristic analysis, the optimal cut-off for E was 0.91m/s (sensitivity 85%%; specificity 77%) and that for E/e’avg was 13 (sensitivity 69%; specificity 82%) to predict mean LAP>12mmHg. When combined the cut-offs of E>0.91m/s and E/e’avg>13 were used, the sensitivity and specificity of predicting elevated LAP were improved to 95% and 96%, respectively.Conclusions: In AF patients, E and E/e’ correlated well with LAP, and a combination of E and average E/e’ improved the accuracy of evaluation of elevated LAP.

Introduction: Echocardiographic assessment of diastolic function during atrial fibrillation (AF) remains challenging due to the irregular cardiac cycle length. We sought to assess whether the index-beat method, the beat following two preceding cardiac cycles of equal duration, could provide a more reliable measurement of E/e′ (mitral E wave/diastolic tissue Doppler velocity) than the conventional averaging of consecutive beats and hence facilitate the non-invasive estimation of elevated left atrial pressure (LAP) in patients with AF. Methods: We prospectively studied 35 patients with persistent AF who had preserved left ventricular ejection fraction and underwent radiofrequency ablation. LAP was measured in conjunction with trans-septal puncture during catheter ablation. Echocardiography was performed 24 h before ablation and E/e′ was determined using the recommended averaging of 10 beats and the index-beat method, with the observers blinded to the clinical details and LAP measurements. Results: Correlation analysis showed a strong positive correlation between two methods in terms of both septal E/e′ (r = 0.841, p < 0.001) and lateral E/e′ (r = 0.930, p < 0.001). Bland-Altman analysis also showed a good agreement between the two measurement methods in terms of E/e′. E/e′ determined using both conventional averaging and the index-beat method was significantly correlated with LAP (p < 0.05). After Fisher Z transformation, we found that the index-beat septal E/e′ had a better correlation with LAP than did the conventional averaging E/e′ (r = 0.736 vs. r = 0.392, Zr = -2.110, p = 0.035). Furthermore, the index-beat method took significantly less time to measure E/e′ (mean 33.6 s; 95% confidence intervals (CI): 32.1s to 36.2s), than did conventional averaging method (mean 96.2 s; 95% CI: 90.2s to 102.3s; p < 0.001). Receiver operating characteristic curve analysis revealed that the optimal cut-off for predicting mean LAP > 12mmHg was 11 (sensitivity 100%; specificity 77.3%) for index-beat septal E/e′ and 16 (sensitivity 61.5%; specificity 95.5%) for index-beat lateral E/e′. Conclusions: Good correlations were found between E/e′ and LAP in patients with AF, particularly with the index-beat method. Moreover, the index-beat method can easily measure E/e′ at an accuracy similar to that for the conventional averaging of consecutive beats, which can therefore be applied to assess the diastolic dysfunction and potentially improve the diagnosis of heart failure in patients with AF.