Successful Management of Atrio-Esophageal Fistula after Cardiac Radiofrequency Catheter Ablation
A previously healthy, 46-year-old man with a 2-year history of atrial fibrillation presented with fever, headache, and dizziness. Three weeks earlier, he had undergone cardiac radiofrequency catheter ablation for symptomatic atrial fibrillation refractory to medical management by a cardiologist. Circumferential ablation of a wide area encircling the four pulmonary vein antra was performed point by point (). The energy was delivered under power control with a maximum pre-set power of average 30 to 35 watts using a Lasso catheter (Lasso; Biosense Webster, Diamond Bar, CA, USA). Three days after the ablation, the patient had a single episode of headache and all other symptoms were resolved. Two weeks later, he developed fever, chills, cough, and headache. Two days after the symptoms started, he visited the emergency room. He was febrile (temperature, 39℃) and hypotensive (blood pressure, 70/55 mmHg) with an irregular heart rate of 120 beats/min. Atrial fibrillation was confirmed by electrocardiography and then he underwent synchronized direct current cardioversion. Although the rhythm was restored by cardioversion, he was noted to be confused, with generalized tonic-clonic seizures. His blood leukocyte count was 16,500 cells/mL, with 87% neutrophilic predominance. Findings of a chest radiograph were unremarkable, and a transthoracic and transesophageal echocardiogram showed no thrombus or vegetation. Empiric treatment with ceftriaxone was initiated, which resulted in resolution of the fever. Magnetic resonance imaging of the brain revealed multifocal infarcts (). Computed tomography of the chest showed a minute air pocket around the left atrium near the level of the esophagus, suggesting an atrio-esophageal fistula (AEF) (). The patient was taken to the operating room to repair the presumed fistula. Through a left posterolateral thoracotomy, adhesion between the esophagus and pericardium was observed, and a fistula between the left atrium and esophagus was found. The atrial lesion (2 cm) was closed with a bovine pericardial patch under cardiopulmonary bypass using a femoral artery and vein. The esophageal lesion (3 cm) was closed with simple interrupted sutures using 3-0 vicryl. Sutures were performed separately in two layers. The mucosal layer was sutured first and the muscle layer was reinforced. No buttressed suture was used because of acute inflammatory tissue around the lesion. Two sets of blood cultures revealed growth of Streptococcus mitis and Streptococcus viridians. He completed a 4-week course of ampicillin/sulbactam and 2-week course of amoxicillin/clavulanate treatment. Seven days after surgery, he underwent a leak test with grape juice and showed no leakage and started to drink water. On the tenth day after surgery, esophagography showed no leakage. He was discharged without any other complications except for mild left arm motor weakness. In follow-up computed tomography (CT) scans after 3 months, ostium of right inferior pulmonary vein stenosis was revealed. In addition, esophagogastroscopy after seven months showed the esophageal defect site to be fully recovered ().