Atrioesophageal fistula with meningitis: A rare complication of atrial fibrillation ablation, case report and literature review

Abstract

Atrioesophageal fistula is a rare, devastating complication of atrial fibrillation ablation, reportedly occurring in 0.015–0.04% of catheter ablations. A 66-year-old African American male with a past medical history of chronic atrial fibrillation status post recent radiofrequency ablation and on chronic anticoagulation with rivaroxaban presented with left upper extremity numbness, tingling, and transient weakness. He was admitted for a cerebrovascular accident workup; a 12-lead electrocardiogram revealed atrial fibrillation and magnetic resonance imaging of the brain was consistent with multifocal embolic infarcts. Hospital course was further complicated by persistent high-grade fevers, gram-positive bacteremia, and worsening mental status requiring mechanical ventilation. Lumbar puncture was consistent with bacterial meningitis. Transthoracic echocardiogram was negative for vegetations. Computed tomography angiography of the chest with intravenous contrast revealed an outpouching off the posterior wall of the left atrium at the level of the inferior pulmonary vein, consistent with an atrioesophageal fistula. We present this case to highlight the clinical features of a rare but potentially fatal complication from a commonly performed procedure requiring prompt recognition and life-saving intervention.

Unusual esophageal injury after atrial fibrillation ablation: Early diagnosis and treatment to optimize outcomes

“…AF ablation provides improved rhythm control and quality of life compared to antiarrhythmic drugs, is associated with improved overall survival in patients with advanced heart failure, and is the standard of care for symptomatic AF refractory to antiarrhythmic drugs. 3 , 4 , 5 The number of AF ablation procedures is growing exponentially, as it is increasingly effective and safe. The mortality rate of AF ablation is at only 0.01%, with the cause of death most commonly related to cardiac tamponade, stroke, or AEF.…”

“… 6 , 9 Injury may progress to AEF days to weeks after ablation, with a peak presentation time of 21 days postablation. 1 , 3 , 8 As esophageal injury progresses to AEF, recurrent strokes, sepsis, and gastrointestinal (GI) bleeding develop. 1 , 3 , 5 , 8 The late presentation, nonspecific symptoms, and failure to report a history of AF ablation frequently results in the misdiagnosis of esophageal injury and AEF.…”

“… 3 The anterior esophageal nerve plexus and esophageal arteries pass millimeters from the pulmonary veins and posterior atrial wall, predisposing the esophagus to thermal injury during catheter ablation. 3 , 7 , 8 …”

“…A contrast esophagram may show extravasation of contrast material. 1 , 3 , 10 Brain imaging that shows air emboli or transthoracic echocardiography that shows an “aquarium sign,” or air bubbles in the left atrium confirm the diagnosis of AEF. 1 , 8 Laboratory studies often show leukocytosis, elevated serum C-reactive protein level, thrombocytopenia, and elevated erythrocyte sedimentation rate.…”

“…Cardiac ablation has a complication rate of less than 5%, and serious, life-threatening complications including cardiac tamponade, pericardial effusion, transient ischemic attack, stroke, pulmonary vein stenosis, and atrioesophageal fistula (AEF) occur in less than 3% of procedures. 2 , 3 Although AEF is rare, patients with AEF suffer a high mortality rate. Early recognition and prompt treatment of esophageal injury are vital to maximizing the probability of a positive outcome.…”