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Neurological Consequences of Atrioesophageal Fistula After Radiofrequency Ablation in Atrial Fibrillation

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Neurological Consequences of Atrioesophageal Fistula After Radiofrequency Ablation in Atrial Fibrillation ORIGINAL CONTRIBUTION Neurological Consequences of Atrioesophageal Fistula After Radiofrequency Ablation in Atrial Fibrillation Claudia Stöllberger, MD; Thomas Pulgram, MD; Josef Finsterer, MD, PhD Background: Radiofrequency ablation for atrial fibril- 21 of 28 patients. Blood tests showed leukocytosis, el- lation (RAF) is an increasingly performed procedure. It evated serum C-reactive protein levels, and thrombocy- is performed during cardiac surgery or percutaneously topenia. Blood cultures were frequently positive for bac- by catheter. A dangerous complication of RAF is atrio- teria. Lumbar puncture revealed pleocytosis, elevated esophageal fistula (AEF), which predominantly mani- protein levels, increased lactate levels, and bacteria. Di- fests neurologically owing to food embolism. Because neu- agnosis was established by thoracic contrast computed rologists may not be familiar with AEF and the prognosis tomography. Endoscopy, insertion of nasogastric tubes, is dependent on a prompt diagnosis, awareness of AEF and transesophageal echocardiography were detrimen- by the neurologist may play a crucial role. tal, leading to an increase in fistula size and food or air embolism. Therapy comprised surgery (n=11) or tem- Objective: To summarize for the neurologist the knowl- porary esophageal stenting (n=1). The remaining pa- edge about fistula between the left atrium and esopha- tients died before attempted surgery or confirmation of gus occurring after RAF. the diagnosis. A neurological deficit persisted in 3 of the 9 surviving patients. Design, Setting, and Patients: Using a MEDLINE search, we collected reports about AEF after RAF in 28 patients. Conclusions: In patients with meningitis, stroke, sei- zures, or impaired consciousness and fever, it should be Main Outcome Measures: From the collected re- determined whether they have had a previous RAF. In ports, the description of symptoms, diagnostic investi- cases with a history of recent RAF, AEF should be strongly gations, therapy, and outcome of the 28 patients were considered, especially if there are also symptoms such summarized. as dysphagia or chest pain. After RAF, the patient, his or her family, and his or her treating physicians should be Results: In 28 cases, AEF developed 3 to 38 days after informed about the signs of AEF, which may occur even RAF. Confusion, grand mal seizures, meningitis, focal cor- weeks after RAF. tical signs, and postprandial transient ischemic attacks associated with fever were the leading manifestations in Arch Neurol. 2009;66(7):884-887 ADIOFREQUENCY ABLATION and the esophagus. The fistula may initially for atrial fibrillation (RAF) andpredominantlymanifestwithneurologi- is an increasingly per- cal abnormalities, and neurological abnor- formed procedure, applied malities are the main cause for hospitaliza- especially in patients with tion of patients with this complication Rparoxysmal atrial fibrillation who are clas- (Table). Neurologists may not be familiar sified as refractory to antiarrhythmic drug withtheclinicalpresentationofthisrarecom- therapy. Radiofrequency ablation for atrial plication.However,theprognosisofpatients fibrillation is performed either during car- with a fistula is highly dependent on prompt diac surgery as an additional procedure or andappropriatediagnosisandtherapy.Thus, as a percutaneous catheter intervention. It awareness of atrioesophageal fistula (AEF) is associated with various complications by the neurologist may play a crucial role in Author Affiliations: Second such as pericardial effusion, pericardial tam- the survival of patients with this life- Medical Department ponade, pulmonary vein stenosis or throm- threatening disease. (Dr Stöllberger) and Fourth 1 Medical Department bosis, and left atrial wall hematoma. The aim of this review is to summa- (Dr Pulgram), Krankenanstalt Probably the most dangerous, life- rize for the neurologist the knowledge Rudolfstiftung (Dr Finsterer), threatening complication of RAF is the de- about fistulas occurring between the left Wien, Austria. velopmentofafistulabetweentheleftatrium atrium and esophagus after RAF. (REPRINTED) ARCH NEUROL / VOL 66 (NO. 7), JULY 2009 WWW.ARCHNEUROL.COM 884 ©2009 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 Table. Patients With Atrioesophageal Fistula After Surgical or Interventional Therapy of Atrial Fibrillation Age, y/ Time After Symptoms Source Sex Procedure Procedure, d and Findings Cerebral Imaging Therapy Outcome Preis et al,2 56/M PRFA 38 Fever, bilateral arm Multiple foci of Surgery Survived, expressive 2007 (n=1) weakness restricted aphasia diffusion Cummings et NR/M=4, PRFA 10-16 Sepsis, embolic strokes Intravascular air NR Died al,3 2006 F=5 (n=8), angina pectoris (n=2) (n=9) (n=2), gastrointestinal bleeding (n=3) Sonmez et al,4 58/F SRFA 22 Fever, numbness of right Ischemic lesions Surgery Died on 20th 2003 (n=1) arm postoperative day Schley et al,5 37/M PRFA 25 Fever, grand mal seizure, NR Surgery attempted Died during 2006 (n=1) status epilepticus preparation for surgery Scanavacca et 72/M PRFA 22 Dysphagia, fever, loss of NR Gastroesophageal Died al,6 2004 consciousness after endoscopy (n=1) eating, tonic-clonic seizures, hematemesis Pappone et al,7 36/M PRFA 3 Fever, pleuritic chest pain, Bilateral ischemia Surgery Survived, left 2004 (n=1) convulsions hemiparesis Pappone et al,7 59/M PRFA 21 Fever, grand mal seizure Cerebral emboli Antibiotics Died 2004 (n=1) Ouchikhe et al,8 58/M PRFA 21 Fever, confusion, meningitis Bilateral hyperdense Antibiotics Died 2008 (n=1) lesions (frontal, occipital, parietal, and temporal) Doll et al,9 2003 42/M SRFA 10 Fever, postprandial NR Surgery Survived (n=1) transient ischemic attack Doll et al,9 2003 62/F SRFA 6 Hematemesis NR Endoscopy Died (n=1) Doll et al,9 2003 59/M SRFA 12 Fever, neurological NR Surgery Survived (n=1) symptoms Doll et al,9 2003 36/M SRFA 11 Chest pain NR Surgery Survived (n=1) Dagres et al,10 Mean, 51 SRFA (n=4), 8-28 Fever (n=3), chest pain NR Surgery (n=3), Survived (n=3), 2006 (n=5) (range, PRFA (n=2), hemiparesis attempted surgery died (n=2) 35-76)/ (n=1) (n=3), grand mal seizure (n=2) M=4, (n=1), aphasia (n=1) F=1 Bunch et al,11 48/M PRFA 14 Fever, chest pain, dysphagia NR Temporary stenting Survived 2006 (n=1) Malamis et al,12 59/M PRFA 35 Fever, altered mental state, Negative for Surgery Died during surgery 2007 (n=1) multiple petechiae ischemic changes Borchert et al,13 59/M HIFU 10 Fever, chest pain, Multiple ischemic Surgery Died on fifth 2008 (n=1) ventricular fibrillation, lesions postoperative day generalized seizures Abbreviations: HIFU, percutaneous high-intensity focused ultrasound ablation; NR, not reported; PRFA, percutaneous radiofrequency ablation; SRFA, surgical radiofrequency ablation. METHODS Esophagoatrial fistula may be due to esophageal in- juries such as perforation with feeding tubes, esopha- Using a MEDLINE search, we collected reports about fistulas geal biopsies, esophageal surgery, erosion of an esoph- between the left atrium and esophagus. We noted this in gen- ageal diverticulum into the left atrium, and carcinoma.14-21 eral and especially as a complication after RAF. In the search, Rheumatic mitral valve disease with an enlarged left atrium we found 28 cases of AEF that developed after RAF. and esophageal compression in association with the in- take of potassium chloride tablets has been reported as RESULTS a further cause of EAF.22 Atrioesophageal fistula has been described as in- ETIOLOGY OF FISTULA BETWEEN ESOPHAGUS duced by trauma such as after a gunshot wound of the AND LEFT ATRIUM chest.23 Atrioesophageal fistula after RAF may develop owing to the proximity between the left atrium and Depending on the site of the primary lesion, esophago- esophagus.24 Myocardial injury during RAF may also affect atrial fistula (EAF) and AEF must be differentiated. the esophageal wall.25 Whether reflux esophagitis, which (REPRINTED) ARCH NEUROL / VOL 66 (NO. 7), JULY 2009 WWW.ARCHNEUROL.COM 885 ©2009 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 has been reported to be associated with paroxysmal atrial tients who develop neurological signs, delays in the diag- fibrillation, favors the development of AEF has not yet nosis probably contribute to the high mortality.10 been investigated to our knowledge.26 To reduce radio- frequency-induced tissue damage, alternative ablation LABORATORY FINDINGS techniques have been developed. However, AEF has also been reported as a complication of ablation using high- Blood tests show leukocytosis, elevation of serum intensity focused ultrasound (Table).13 C-reactive protein levels, thrombocytopenia, and an elevated erythrocyte sedimentation rate. Blood cultures PATHOLOGIC CONSEQUENCES are frequently positive for bacteria. Lumbar puncture may OF THE FISTULA reveal pleocytosis, elevated protein levels, increased lac- tate levels, and bacteria.8 A fistula between the left atrium and esophagus may lead to severe bleeding and food emboli. One might expect DIAGNOSIS hemorrhage to be more common than food emboli be- cause at rest, left atrial pressure exceeds esophageal pres- Chest radiography or computed tomography of the chest sure. The lower viscosity of blood as compared with the may be diagnostic if air is visualized within the cardiac cavi- viscosity of food would further increase the likelihood ties or in the mediastinum, or if intravenous contrast me- of gastrointestinal bleeding.21
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