Cardiol Res

Cardiology Research, ISSN 1923-2829 print, 1923-2837 online, Open Access

Article copyright, the authors; Journal compilation copyright, Cardiol Res and Elmer Press Inc

Journal website https://www.cardiologyres.org

Case Report

Volume 7, Number 1, February 2016, pages 36-45

Management of Atrio-Esophageal Fistula Following Left Atrial Ablation

Figure 1. X-ray esophagus with gastrografin showing sinus tracts extending from anterior aspect of esophagus.

Figure 2. X-ray esophagus with gastrografin showing two sinus tracts extending from anterior aspect of esophagus at level T7.

Figure 3. CTA of the chest and abdomen identified esophageal perforation with a fistulous tract to the left atrium.

Figure 4. Esophagogram showing extravasation of contrast from posterolateral aspect of esophagus.

**Table 1.** Descriptions of Published Case Reports and Case Series With AEF After Ablation for Atrial Fibrillation
Lead author, year	NP	Age	Sex	LAOC	Clinical manifestations	Treatment	Outcome
NP: number of patients; M: male; F: female; PR: procedure: LAOC: latency between ablation and onset of clinical manifestations (days); 1 week = 7 days; 1 month = 30 days; NR: not reported. ^aBorchert, 2008 and Neven, 2010 used HIFU (high-intensity focused US) to treat atrial fibrillation.
Mohr, 2002 [6]	3	NR	NR	3 - 6	Neurological symptoms (2): stroke (2); GI bleeding	Surgery (2)	Survived (2) (surgery); died
Kottkamp, 2002 [7]	1	NR	NR	10	Fever (septicemic), neurological symptoms	Surgery	Survived
Doll, 2003 [8]	4	36 - 62	M (3), F (1)	3 - 12	Fever (2), hematemesis, chest pain, neurological symptoms (2): TIA	Surgery (3), antibiotics, died during gastroscopy	Survived (3), died
Sonmez, 2003 [9]	1	58	F	22	Fever, shivering, neurological symptoms: numbness in right arm	Surgery	Died
Pappone, 2004 [10]	2	36, 59	M (2)	3, 2	Fever (2), rigors, chest pain (2), neurological symptoms (2): convulsions, loss of consciousness, left-sided hemiparesis, weakness, grand mal seizure, stroke	Surgery, antibiotics	Survived; died
Scanavacca, 2004 [11]	1	72	M	20	Fever, hematemesis, neurologic symptoms: loss of consciousness, tonic-clonic seizures; dysphagia, anorexia	Antibiotics	Died following endoscopy
Dagres, 2006 [12]	5	35 - 76 (mean 51)	M (4), F (1)	8 - 28	Fever (3), chest pain (2), neurological symptoms (3): hemiparesis (3), grand mal seizure, aphasia	Surgery (3), died before surgery, died during gastroscopy	Survived (3) (surgery), died (2)
Schley, 2006 [13]	1	37	M	25	Fever, neurological symptoms: grand mal seizure, status epilepticus, loss of consciousness	Died before surgery	Died
Cummings, 2006 [14]	9	NR	M (4), F (5)	10 - 16 (mean 12.3)	Fever (9) (sepsis), chest pain (2), neurological symptoms (8), GI bleeding (3), occult bleeding (5)	Surgery (3), 1 died before surgery	Died (9)
Gerstenfeld, 2007 [15]	1	NR	NR	21	NR	NR	Died
Malamis, 2007 [16]	1	59	M	35 (5 weeks)	Fever (sepsis), neurological symptoms: confusion, altered mental status	Surgery (died in surgery)	Died
Preis, 2007 [17]	1	56	M	38	Fever, chills, neurological symptoms: right arm weakness, aphasia, stroke	Surgery	Survived
Dixit, 2008 [18]	1	NR	F	14	Fever, hematemesis, neurological symptoms: coma; nausea	Endoscopy	Died
Borchert, 2008 [19]^a	1	59	M	10	Fever (sepsis), chest pain, neurological symptoms: seizure, coma	Surgery	Died
Ouchikhe, 2008 [20]	1	58	M	21 (3 weeks)	Fever (septic shock), neurological symptoms: meningitis, confusion; vomiting	Antibiotics	Died
Hazell, 2009 [21]	1	72	M	24	Rigors, neurological symptoms: weakness, collapse, loss of consciousness, disorientation	Stent placement, antibiotics	Died
Cappato, 2009 [22]	7	NR	NR	NR	NR	NR	Survived (2); died (5)
Ghia, 2009 [23]	6	NR	NR	NR	Neurological symptoms (6): cerebrovascular events (6)	NR	Survived (1); died (5)
Khandhar, 2010 [24]	1	46	M	27	Fever, neurological symptoms: transient left-sided hemiparesis, aphasia	Surgery	Survived
Gilcrease, 2010 [25]	1	61	M	10	Fever, hematemesis, chest pain, neurological symptoms: altered and variable mental status, seizures; fatigue, dysphagia	Surgery	Died
Baker, 2010 [26]	1	65	F	20	Fever, neurological symptoms: confusion, tonic-clonic seizure, stroke; GI bleeding, MI	Died before surgery	Died
Cazavet, 2010 [27]	1	35	M	38	Fever, chest pain, neurological symptoms: left-sided hemiplegia, convulsive crisis; vomiting	Stent placed and migrated requiring surgical intervention, antibiotics	Survived
Neven, 2010 [28]^a	1	69	M	31	Hematemesis, neurological symptoms: seizures; pneumonia	None	Died
Siegel, 2010 [29]	1	46	M	3	Fever (sepsis), neurological symptoms: right-sided hemiparesis, rigors, near-syncope, myoclonic jerking, confusion, positive Babinski signs	Surgery, antibiotics	Survived
Zellerhoff, 2011 [30]	1	63	M	14 (2 weeks)	Fever, neurological symptoms: muscles weakness in arms and legs, left-sided hemiparesis	Stent placement	Died
St Julien, 2011 [31]	1	59	M	42 (6 weeks)	Fever, chest pain, neurological symptoms: headache, altered mental status, aphasia, right hemiplegia, TIA, seizures; GI bleeding, diaphoresis	Surgery, antibiotics	Survived
Tancevski, 2012 [32]	1	45	M	42 (6 weeks)	Fever, neurological symptoms: weakness, sensory loss of the right limbs	Surgery, antibiotics	Survived
Haggerty, 2012 [33]	1	27	M	22	Fever, chills, hematemesis	Surgery, antibiotics	Survived
Hartman, 2012 [34]	1	62	M	30 days (1 month)	Fever, chills, neurological symptoms: rigors, syncope, left-sided hemiplegia, grand mal seizure; odynophagia, nausea, vomiting, abdominal pain	Surgery, antibiotics	Survived
Stockigt, 2012 [35]	1	78	M	28 days (4 weeks)	Fever, shivering, neurological symptoms: stroke, persistent vegetative state; coughing	Surgery, antibiotics	Survived
Tan, 2013 [36]	1	67	F	20	Fever, neurological symptoms: numbness in left foot, unresponsiveness; nausea	Antibiotics	Died
Rivera, 2013 [37]	1	50	F	28 (4 weeks)	Hematemesis	Surgery	Survived
Aryana, 2013 [38]	1	55	F	21 (3 weeks)	Neurological symptoms: seizures, left hemiparesis	Surgery	Died
Shim, 2013 [39]	1	68	M	50	Fever (sepsis), neurological symptoms: stroke	None	Died
Mohanty, 2014 [40]	9	46 - 62 (mean 53.3)	M (8), F (1)	14 - 42 (2 - 6 weeks) (mean 27.2)	Fever (7) (sepsis (3)), rigors (2), chest pain (7), neurological symptoms (9): stroke/TIA (9), confusion, weakness (3), seizure (2), hemiparesis (3), blindness (2), convulsions, altered mental status; GI bleeding (2), dysphagia	Stent placement (5), surgery (4)	Died (5) (stent placement); survived (4) (surgery)
Rajapaksha, 2014 [41]	1	43	M	NR	Chest pain, hematemesis, hemoptysis, neurological symptoms: right arm weakness; throat pain, dyspnea, palpitations, nausea	None	Died
Vilades Medel, 2014 [42]	1	31	M	28 (4 weeks)	Fever (septic shock), hemoptysis, neurological symptoms: headache, absence seizures, intracranial bleed	Surgery	Died
Lim, 2014 [43]	1	61	M	30 (1 month)	Fever, chills, rigors	Stent placement	Died
Shiraishi, 2014 [44]	1	49	M	31	Fever, neurological symptoms: seizures	Endoscopic snaring, antibiotics	Survived
Kawasaki, 2014 [45]	3	58, 48, 75	F, M, F	12, 3, 3	Fever (2), chills (2), rigors (3), neurological symptoms (3): TIA, collapse, left-sided hemiplegia/paresis, weakness in right arm, facial drooping with slurred speech, altered mental status; dysphagia, fatigue, palpitations, abdominal pain	Surgery (2), antibiotics (3)	Died (3)
Schouver, 2014 [46]	1	63	M	15	Fever (septic shock), neurological symptoms: stroke; ST elevation inferior coronary syndrome, acute renal failure, DIC	NR	NR
Koa-Wing, 2014 [47]	1	45	M	21 (3 weeks)	Neurological symptoms: unconsciousness, stroke	None	Died
Hirji, 2015 [48]	1	46	M	7 (1 week)	Fever, neurological symptoms: confusion, right-sided weakness, difficulty walking, meningitis	Surgery, antibiotics, postoperative hyperbaric oxygen therapy (HBOT)	Survived

Table 1. Descriptions of Published Case Reports and Case Series With AEF After Ablation for Atrial Fibrillation

Lead author, year

Age

Sex

LAOC

Clinical manifestations

Treatment

Outcome

NP: number of patients; M: male; F: female; PR: procedure: LAOC: latency between ablation and onset of clinical manifestations (days); 1 week = 7 days; 1 month = 30 days; NR: not reported. ^aBorchert, 2008 and Neven, 2010 used HIFU (high-intensity focused US) to treat atrial fibrillation.

Mohr, 2002 [6]

3 - 6

Neurological symptoms (2): stroke (2); GI bleeding

Surgery (2)

Survived (2) (surgery); died

Kottkamp, 2002 [7]

Fever (septicemic), neurological symptoms

Surgery

Survived

Doll, 2003 [8]

36 - 62

M (3), F (1)

3 - 12

Fever (2), hematemesis, chest pain, neurological symptoms (2): TIA

Surgery (3), antibiotics, died during gastroscopy

Survived (3), died

Sonmez, 2003 [9]

Fever, shivering, neurological symptoms: numbness in right arm

Surgery

Died

Pappone, 2004 [10]

36, 59

M (2)

3, 2

Fever (2), rigors, chest pain (2), neurological symptoms (2): convulsions, loss of consciousness, left-sided hemiparesis, weakness, grand mal seizure, stroke

Surgery, antibiotics

Survived; died

Scanavacca, 2004 [11]

Fever, hematemesis, neurologic symptoms: loss of consciousness, tonic-clonic seizures; dysphagia, anorexia

Antibiotics

Died following endoscopy

Dagres, 2006 [12]

35 - 76 (mean 51)

M (4), F (1)

8 - 28

Fever (3), chest pain (2), neurological symptoms (3): hemiparesis (3), grand mal seizure, aphasia

Surgery (3), died before surgery, died during gastroscopy

Survived (3) (surgery), died (2)

Schley, 2006 [13]

Fever, neurological symptoms: grand mal seizure, status epilepticus, loss of consciousness

Died before surgery

Died

Cummings, 2006 [14]

M (4), F (5)

10 - 16 (mean 12.3)

Fever (9) (sepsis), chest pain (2), neurological symptoms (8), GI bleeding (3), occult bleeding (5)

Surgery (3), 1 died before surgery

Died (9)

Gerstenfeld, 2007 [15]

Died

Malamis, 2007 [16]

35 (5 weeks)

Fever (sepsis), neurological symptoms: confusion, altered mental status

Surgery (died in surgery)

Died

Preis, 2007 [17]

Fever, chills, neurological symptoms: right arm weakness, aphasia, stroke

Surgery

Survived

Dixit, 2008 [18]

Fever, hematemesis, neurological symptoms: coma; nausea

Endoscopy

Died

Borchert, 2008 [19]^a

Fever (sepsis), chest pain, neurological symptoms: seizure, coma

Surgery

Died

Ouchikhe, 2008 [20]

21 (3 weeks)

Fever (septic shock), neurological symptoms: meningitis, confusion; vomiting

Antibiotics

Died

Hazell, 2009 [21]

Rigors, neurological symptoms: weakness, collapse, loss of consciousness, disorientation

Stent placement, antibiotics

Died

Cappato, 2009 [22]

Survived (2); died (5)

Ghia, 2009 [23]

Neurological symptoms (6): cerebrovascular events (6)

Survived (1); died (5)

Khandhar, 2010 [24]

Fever, neurological symptoms: transient left-sided hemiparesis, aphasia

Surgery

Survived

Gilcrease, 2010 [25]

Fever, hematemesis, chest pain, neurological symptoms: altered and variable mental status, seizures; fatigue, dysphagia

Surgery

Died

Baker, 2010 [26]

Fever, neurological symptoms: confusion, tonic-clonic seizure, stroke; GI bleeding, MI

Died before surgery

Died

Cazavet, 2010 [27]

Fever, chest pain, neurological symptoms: left-sided hemiplegia, convulsive crisis; vomiting

Stent placed and migrated requiring surgical intervention, antibiotics

Survived

Neven, 2010 [28]^a

Hematemesis, neurological symptoms: seizures; pneumonia

None

Died

Siegel, 2010 [29]

Fever (sepsis), neurological symptoms: right-sided hemiparesis, rigors, near-syncope, myoclonic jerking, confusion, positive Babinski signs

Surgery, antibiotics

Survived

Zellerhoff, 2011 [30]

14 (2 weeks)

Fever, neurological symptoms: muscles weakness in arms and legs, left-sided hemiparesis

Stent placement

Died

St Julien, 2011 [31]

42 (6 weeks)

Fever, chest pain, neurological symptoms: headache, altered mental status, aphasia, right hemiplegia, TIA, seizures; GI bleeding, diaphoresis

Surgery, antibiotics

Survived

Tancevski, 2012 [32]

42 (6 weeks)

Fever, neurological symptoms: weakness, sensory loss of the right limbs

Surgery, antibiotics

Survived

Haggerty, 2012 [33]

Fever, chills, hematemesis

Surgery, antibiotics

Survived

Hartman, 2012 [34]

30 days (1 month)

Fever, chills, neurological symptoms: rigors, syncope, left-sided hemiplegia, grand mal seizure; odynophagia, nausea, vomiting, abdominal pain

Surgery, antibiotics

Survived

Stockigt, 2012 [35]

28 days (4 weeks)

Fever, shivering, neurological symptoms: stroke, persistent vegetative state; coughing

Surgery, antibiotics

Survived

Tan, 2013 [36]

Fever, neurological symptoms: numbness in left foot, unresponsiveness; nausea

Antibiotics

Died

Rivera, 2013 [37]

28 (4 weeks)

Hematemesis

Surgery

Survived

Aryana, 2013 [38]

21 (3 weeks)

Neurological symptoms: seizures, left hemiparesis

Surgery

Died

Shim, 2013 [39]

Fever (sepsis), neurological symptoms: stroke

None

Died

Mohanty, 2014 [40]

46 - 62 (mean 53.3)

M (8), F (1)

14 - 42 (2 - 6 weeks)
(mean 27.2)

Fever (7) (sepsis (3)), rigors (2), chest pain (7), neurological symptoms (9): stroke/TIA (9), confusion, weakness (3), seizure (2), hemiparesis (3), blindness (2), convulsions, altered mental status; GI bleeding (2), dysphagia

Stent placement (5), surgery (4)

Died (5) (stent placement); survived (4) (surgery)

Rajapaksha, 2014 [41]

Chest pain, hematemesis, hemoptysis, neurological symptoms: right arm weakness; throat pain, dyspnea, palpitations, nausea

None

Died

Vilades Medel, 2014 [42]

28 (4 weeks)

Fever (septic shock), hemoptysis, neurological symptoms: headache, absence seizures, intracranial bleed

Surgery

Died

Lim, 2014 [43]

30 (1 month)

Fever, chills, rigors

Stent placement

Died

Shiraishi, 2014 [44]

Fever, neurological symptoms: seizures

Endoscopic snaring, antibiotics

Survived

Kawasaki, 2014 [45]

58, 48, 75

F, M, F

12, 3, 3

Fever (2), chills (2), rigors (3), neurological symptoms (3): TIA, collapse, left-sided hemiplegia/paresis, weakness in right arm, facial drooping with slurred speech, altered mental status; dysphagia, fatigue, palpitations, abdominal pain

Surgery (2), antibiotics (3)

Died (3)

Schouver, 2014 [46]

Fever (septic shock), neurological symptoms: stroke; ST elevation inferior coronary syndrome, acute renal failure, DIC

Koa-Wing, 2014 [47]

21 (3 weeks)

Neurological symptoms: unconsciousness, stroke

None

Died

Hirji, 2015 [48]

7 (1 week)

Fever, neurological symptoms: confusion, right-sided weakness, difficulty walking, meningitis

Surgery, antibiotics, postoperative hyperbaric oxygen therapy (HBOT)

Survived

**Table 2.** Summary Table
Total number of patients with reported AEF	82
Males	44
Females	16
Not specified	22
Average reported age	54.0 years old
Average latency between therapeutic procedure and onset of clinical manifestations *Borchert, 2008 and Neven, 2010 used HIFU (high-intensity focused US) to treat atrial fibrillation	20.1 days
Clinical manifestations	74 patients’ manifestations reported
Neurological symptoms Stroke/TIA Confusion Seizure Paresis Sensory disturbance	65 (87.8%)
Fever/chills/shivering/rigors	54 (73.0%)
Chest pain	19 (25.7%)
Hematemesis/hemoptysis	9 (12.2%)
GI bleeding	8 (10.8%)
Therapeutic intervention of AEF
Stent placement	8
Surgery	36
Medical management alone	23
Mortality rate following intervention
Stent placement	100% (8/8)
Surgery	33.3% (12/36)
Medical management	95.6 % (22/23)
Total reported mortalities	53
Total reported survivors	29

Table 2. Summary Table

Total number of patients with reported AEF

Males

Females

Not specified

Average reported age

54.0 years old

Average latency between therapeutic procedure and onset of clinical manifestations
*Borchert, 2008 and Neven, 2010 used HIFU (high-intensity focused US) to treat atrial fibrillation

20.1 days

Clinical manifestations

74 patients’ manifestations reported

Neurological symptoms
Stroke/TIA
Confusion
Seizure
Paresis
Sensory disturbance

65 (87.8%)

Fever/chills/shivering/rigors

54 (73.0%)

Chest pain

19 (25.7%)

Hematemesis/hemoptysis

9 (12.2%)

GI bleeding

8 (10.8%)

Therapeutic intervention of AEF

Stent placement

Surgery

Medical management alone

Mortality rate following intervention

Stent placement

100% (8/8)

Surgery

33.3% (12/36)

Medical management

95.6 % (22/23)

Total reported mortalities

Total reported survivors