Korean Circ J.  2017 Nov;47(6):970-977. 10.4070/kcj.2016.0364.

Pericardial-esophageal Fistula Complicating Atrial Fibrillation Ablation Successfully Resolved after Pericardial Drainage with Conservative Management

• Seo JM
• Park JS
• Jeong SS

• KMID: 2396490
• DOI: http://doi.org/10.4070/kcj.2016.0364

Abstract

A 40-year-old male patient underwent radiofrequency catheter ablation for symptomatic paroxysmal atrial fibrillation (AF). Although pulmonary vein (PV) isolation was successfully completed without acute complications, the patient began complaining of sustained retrosternal pain. Seventeen days after ablation, the patient visited the emergency room with fever and severe chest pain with pericarditis-like features. Chest computed tomography (CT) revealed clustered air bubbles in the pericardial space. Esophagography confirmed leakage of contrast agent into the pericardial space but not into the left atrium. While performing pericardiostomy, the operator confirmed the absence of active bleeding from the left atrium. Because there were no signs of left atrial-esophageal fistula, such as systemic embolization, conservative management based on strict fasting with fluids and antibiotic therapy was undertaken. Follow-up esophagography performed 2 weeks later showed no more contrast agent leakage, and the patient was discharged without further incident.

Keyword

Atrial fibrillation; Catheter ablation; Complications; Esophagus; Fistula

MeSH Terms

Adult
Atrial Fibrillation*
Catheter Ablation
Chest Pain
Drainage*
Emergency Service, Hospital
Esophagus
Fasting
Fever
Fistula*
Follow-Up Studies
Heart Atria
Hemorrhage
Humans
Male
Pericardial Window Techniques
Pericardium
Pulmonary Veins
Thorax

Figure

• 

  Figure 1 Radiofrequency ablation findings. (A, B) Electroanatomic mapping images of the left atrium acquired by the CARTO 3 Navigation System show that linear ablation at the posterior wall was performed in front of the esophagus during left-side antral ablation. (B) Intracardiac electrograms recorded by the ablation catheter (AB 1–2 and AB 3–4) during left-side posterior wall ablation show stable left atrial potentials that ranged from 0.8–1.4 mV. The tip of the ablation catheter tightly contacts the left atrial endocardium at a less than 2 mm distance to the esophagus. AB = ablation catheter electrodes; CS = coronary sinus catheter electrodes.

• 

  Figure 2 Clinical events by date. AF = atrial fibrillation; CT = computed tomography.

• 

  Figure 3 Chest X-ray findings. (A) Initial chest X-ray image in posteroanterior projection does not show cardiomegaly or pleural effusion. (B) Chest X-ray image acquired 2 days after esophageal perforation shows an air-line and bubbles within the cardiac silhouette (arrows) in anteroposterior projection.

• 

  Figure 4 Chest CT scan findings. (A) An initial chest CT image shows clusters of small air bubbles (black arrow) in the pericardial space, which is highly suggestive of an esophageal perforation. However, there were no air bubbles within the left atrium. Left atrial posterior wall thickness was less than 2 mm, and intervening connective and fat tissues between the left atrial posterior and esophageal walls were virtually absent. (B) Chest CT image acquired 22 days after esophageal perforation shows large air bubbles (white arrow) remaining in the pericardial space. However, there were no further complications. CT = computed tomography.

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  Figure 5 Esophagography findings. Initial esophagography shows contrast agent (arrows) leaking from the mid-esophagus into the pericardial space at the level of 9 cm above the esophagogastric junction (A, B). Follow-up esophagography shows no more contrast agent leakage into the pericardial space (C, D). Radiologic findings that reveal the presence of esophageal ulcer or stricture were not observed on the initial or follow-up esophagography images.

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