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J Thorac Cardiovasc Surg 2003;126:1662-1663
© 2003 The American Association for Thoracic Surgery

Letters to the editor

Atrioesophageal fistula: is it an unavoidable complication of radiofrequency ablation?

Bingur Sonmez, MDa, Ergun Demirsoy, MDa, Oguz Yilmaz, MDa

a Istanbul Memorial Hospital, Department of Cardiovascular Surgery, Istanbul, Turkey

To the Editors:

The article by Doll and colleagues1 was of great interest. We want to share a similar experience where a patient (1 of 42) died of an atrioesophageal fistula.

Clinical summary

A 58-year-old female patient with rheumatic valve disease, osteal stenosis of the right coronary artery (RCA), chronic atrial fibrillation, and a dilated left atrium (78 mm) was operated through a median sternotomy for the replacement of the aortic and mitral valves with mechanical prosthesis, De Vega annuloplasty of the tricuspid valve, bypass graft to the RCA, and a left atrial radiofrequency ablation (RFA) using the Cobra RF System (Boston Scientific, Boston, Mass) with the technique of Melo and colleagues.2 The patient was discharged on postoperative day 7 with no complication but paroxysmal atrial fibrillo-flutter despite amiodarone.

On the postoperative day 22, she was readmitted with fever, shivering, and numbness of the right arm. Echocardiography revealed a left atrial thrombus. The next day the patient suddenly lost consciousness and was immediately operated for thrombectomy from the left atrial cavity. After easy weaning from cardiopulmonary bypass (CPB), we noted a massive hemorrhage through the nasogastric tube. Esophagoscopy showed a 15-mm laceration on the anterior wall, 33 cm from the incisors. We restored CPB. Air bubbles could be noticed within the left atrium. A fistula between the esophagus and the laceration on the atrial wall between the right and left pulmonary vein orifices was detected. The defect was repaired with pericardial-pledgeted sutures. At the end of the operation the patient was transferred to the intensive care unit. Brain computed tomography 24 hours later showed diffuse ischemic lesions in both cerebral hemispheres. The neurologic state of the patient never improved and she died from multiorgan failure on day 20 after the second operation.

Discussion

The primary suspected diagnosis at readmission was infective endocarditis, so heparin and empirical antibiotherapy was instituted. The presence of air bubbles within the left atrium and the finding of diffuse ischemia in both cerebral hemispheres led us to think that the probable cause of cerebral ischemia was the air insufflated during the endoscopy, which embolized to the brain.

After such an experience, we now perform the transverse ablation line between the right and left pulmonary vein orifices as high as possible. In patients with a small left atrial cavity, care should be taken to prevent the overlapping of the 2 circles around the right and left pulmonary vein orifices to avoid extreme thermal injury at any single point on the posterior left atrial wall neighboring the esophagus (Figure 1). We think that temperature and the duration of application of the probe should either be reduced or RFA should be avoided in patients with large thin-walled left atria.



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  		Figure 1. A, The connecting points of 2 overlapping circles (arrows) around right and left pulmonary veins are the stress points receiving twice the dose of RF, thus are the most vulnerable points in the posterior wall of the left atrium neighboring the esophagus. B, Connecting line between 2 circles should be as high as possible to avoid heat injury of the esophagus (the hatched area represents the posterior wall of the left atrium in close neighborhood with the esophagus). RSPV, Right superior pulmonary vein; RIPV, right inferior pulmonary vein; LSPV, left superior pulmonary vein; LIPV, left inferior pulmonary vein.

 
In case of suspicion of an atrioesophageal fistula, no endoscopic intervention should ever be attempted. Although highly lethal, we don't believe that this rare complication should lead to the abandonment of this technique.

References

  1. Doll N, Borger MA, Fabricius A, et al. Esophageal perforation during left atrial radiofrequency ablation: is the risk too high? J Thorac Cardiovasc Surg. 2003;125:836–842[Abstract/Free Full Text]
  2. Melo JQ, Neves J, Adrago P, et al. When and how to report results of surgery on atrial fibrillation. Eur J Cardiothorac Surg. 1997;12:739–745[Abstract/Free Full Text]

Related Article

Reply to the Editor
Nicolas Doll, Michael A. Borger, and Friedrich W. Mohr
J. Thorac. Cardiovasc. Surg. 2003 126: 1663. [Extract] [Full Text] [PDF]



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