Background:Left atrial-esophageal fistula is an often lethal complication of left atrial radiofrequency catheter ablation (RFA) for atrial fibrillation.This clinical case report describes a diagnostic approach and successful surgical outcome.
Methods:A 52 year old male with paroxysmal atrial fibrillation underwent uneventful RFA. Transient odynophagia and dysphagia occurred one day post ablation followed by a normal CT scan. These symptoms resolved fully. The patient was admitted one month later with rigors,blurred vision and extremity weakness. Workup,including CT scan, was again unremarkable. He was discharged only to return within hours with recurrent similar symptoms. Blood cultures were positive for gram positive cocci. A barium esophagogram demonstrated a 1-2 cm outpouching of the esophagus at the level of the left atrium.Transient hemiparesis followed. MRI of the brain was negative. A transthoracic echo and a thin- slice CT scan demonstrated air in the left atrial appendage and the left ventricular apex.
Results: The patient underwent emergency repair of the esophageal injury as well as suture repair of the left atrial/left inferior pulmonary vein. He experienced a complete recovery ( with interval laparoscopic cholecystectomy).
Conclusion: A high index of suspicion leading to early diagnosis and prompt surgical intervention improves the chance of a successful outcome. Transthoracic echo or intracoronary echo (ICE) and thin-slice CT,especially if intracavitary air is demonstrated, are diagnostic.A positive finding of air is enhanced if the transthoracic echo or thin-slice CT is performed immediately following the barium study. Emergent surgical intervention with local esophageal repair or extensive resection is indicated to avoid an otherwise fatal outcome.