Fatal esophageal–pericardial fistula as a complication of radiofrequency catheter ablation

Abstract

The clinical role of catheter ablation using radiofrequency or cryothermal energy has become an important therapy in the management of patients with recurrent or persistent tachyarrhythmia that is refractory to medical therapy. It is regarded as a safe and reliable procedure and is performed routinely in health care facilities across the country. Like all procedures, there are associated risks and benefits. Development of an esophageal–atrial fistula is a rare but often-fatal complication of radiofrequency ablation. It is the second most frequent cause of death caused by the procedure, with mortality rates in excess of 70%. Death usually occurs as a result of cerebral or myocardial air embolism, endocarditis, massive gastrointestinal bleeding, and/or septic shock. Electrophysiologists have instituted a number of safeguard techniques to diminish the risk of developing esophageal–atrial fistula. Despite these measurements, instances of fistulous development still occur. Herein, we report a case of a 74-year-old male who presented with chest pain secondary to esophageal–pericardial fistula 19 days after pulmonary vein isolation using radiofrequency energy for atrial fibrillation in order to illustrate the clinical variability and diagnostic challenges associated with this dreaded gastrointestinal complication.

Esophago‐pericardial fistula after catheter ablation of atrial fibrillation: A review

“…When reviewing the literature regarding esophago-mediastinal fistulous formation, we found 23 cases of esophageal perforation without a fistulous communication with the left atrium. 6,7,[11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26] Only one of the 23 cases was screened early after ablation having a normal esophagoscopy, before developing perforation two weeks later 4 (Table 1). Park et al 4 also reported that another patient, who likely died of esophageal-atrial fistula, had a normal endoscopy on the second day after the procedure.…”

“…In that light, we report our patient who developed esophago‐pericardial fistula three weeks after radiofrequency pulmonary vein isolation, who had a normal esophagoscopy after the procedure. When reviewing the literature regarding esophago‐mediastinal fistulous formation, we found 23 cases of esophageal perforation without a fistulous communication with the left atrium 6,7,11–26 . Only one of the 23 cases was screened early after ablation having a normal esophagoscopy, before developing perforation two weeks later 4 (Table 1).…”

Cooling or Warming the Esophagus to Reduce Esophageal Injury During Left Atrial Ablation in the Treatment of Atrial Fibrillation

“…The attainment of PVI can be achieved with radiofrequency (RF) energy to burn atrial tissue or with direct application of cryothermal energy; however, collateral damage to surrounding structures remains a risk with either method, with esophageal injury being one of the most serious 2,3,4 . The most extreme esophageal injury, atrioesophageal fistula (AEF), remains challenging to prevent and diagnose, and carries a very high mortality 5,6 .…”

Esophageal cooling for protection during left atrial ablation: a systematic review and meta-analysis

“…Thermal damage to the esophagus is a risk from radiofrequency (RF) ablation or cryoablation of the left atrium for the treatment of atrial fibrillation (AF) [1][2][3]. The most extreme type of thermal injury is an atrioesophageal fistula (AEF), with a mortality rate of 80% or more [4][5][6][7][8]. Various strategies for protecting the esophagus during RF ablation or reducing the severity of injury have been developed, including power reduction, avoidance of greater contact force, temperature monitoring, esophageal deviation, and esophageal cooling, with varying degrees of success [9][10][11].…”