Atrio-esophageal fistula: Difference between revisions
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==Background== | ==Background== | ||
[[File:Gray1032.png|thumb|Posterior view of the position and relation of the esophagus in the cervical region and in the posterior mediastinum.]] | [[File:Gray1032.png|thumb|Posterior view of the position and relation of the esophagus in the cervical region and in the posterior mediastinum.]] | ||
[[File:Layers of the GI Tract english.svg|thumb|Layers of the GI track: the mucosa, submucosa, muscularis, and serosa.]] | [[File:Layers of the GI Tract english.svg|thumb|Layers of the GI track: the mucosa, submucosa, muscularis, and serosa.]] | ||
[[File:Illu esophagus.jpg|thumb|Esophagus anatomy and nomenclature based on two systems.]] | [[File:Illu esophagus.jpg|thumb|Esophagus anatomy and nomenclature based on two systems.]] | ||
[[File:PMC2922872 ipej100339-08.png|thumb|CT showing anatomic relationship between an enlarged left atrium (LA) and esophagus (ESO): atrium abuts and indents into the anterior wall of the esophagus.]] | [[File:PMC2922872 ipej100339-08.png|thumb|CT showing anatomic relationship between an enlarged left atrium (LA) and esophagus (ESO): atrium abuts and indents into the anterior wall of the esophagus.]] | ||
*Rare but deadly complication of atrial [[Cardiac ablation complications|ablation]] | *Rare but deadly complication of atrial [[Special:MyLanguage/Cardiac ablation complications|ablation]] | ||
*There have been reported cases with various ablation modalities (including radiofrequency ablation, cryoablation, high intensity focused ultrasound, and surgical ablation) | *There have been reported cases with various ablation modalities (including radiofrequency ablation, cryoablation, high intensity focused ultrasound, and surgical ablation) | ||
*Incidence is low (<0.1%) <ref> Nair KK, Danon A, Valaparambil A, Koruth JS, Singh SM. Atrioesophageal Fistula: A Review. J Atr Fibrillation. 2015;8(3):1331. Published 2015 Oct 31. doi:10.4022/jafib.1331 </ref> | *Incidence is low (<0.1%) <ref> Nair KK, Danon A, Valaparambil A, Koruth JS, Singh SM. Atrioesophageal Fistula: A Review. J Atr Fibrillation. 2015;8(3):1331. Published 2015 Oct 31. doi:10.4022/jafib.1331 </ref> | ||
*Usually formed between esophagus and left atrium | *Usually formed between esophagus and left atrium | ||
*Thought to be related to adverse healing secondary to esophageal injury during the ablation procedure | *Thought to be related to adverse healing secondary to esophageal injury during the ablation procedure | ||
==Clinical Features== | ==Clinical Features== | ||
*Most common presenting symptoms: | *Most common presenting symptoms: | ||
**[[Fever]] | **[[Special:MyLanguage/Fever|Fever]] | ||
**Neurological symptoms (including [[focal neurological symptoms]], [[seizure]], [[AMS]]) | **Neurological symptoms (including [[Special:MyLanguage/focal neurological symptoms|focal neurological symptoms]], [[Special:MyLanguage/seizure|seizure]], [[Special:MyLanguage/AMS|AMS]]) | ||
**Gastrointestinal symptoms (including [[hematemesis]], [[melena]], [[dysphagia]], [[nausea/vomiting]]) | **Gastrointestinal symptoms (including [[Special:MyLanguage/hematemesis|hematemesis]], [[Special:MyLanguage/melena|melena]], [[Special:MyLanguage/dysphagia|dysphagia]], [[Special:MyLanguage/nausea/vomiting|nausea/vomiting]]) | ||
**[[Chest pain]] | **[[Special:MyLanguage/Chest pain|Chest pain]] | ||
*Most common time frame to presentation is 2-4 weeks post procedure but can occur up to 2 months post procedure | *Most common time frame to presentation is 2-4 weeks post procedure but can occur up to 2 months post procedure | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
*[[Sepsis]] | |||
*[[Stroke]]/[[TIA]] | *[[Special:MyLanguage/Sepsis|Sepsis]] | ||
*[[GI bleed]] | *[[Special:MyLanguage/Stroke|Stroke]]/[[Special:MyLanguage/TIA|TIA]] | ||
*[[Special:MyLanguage/GI bleed|GI bleed]] | |||
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{{Chest Pain DDX}} | {{Chest Pain DDX}} | ||
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==Evaluation== | ==Evaluation== | ||
[[File:PMC3631790 kjtcs-46-142-g003.png|thumb|Chest CT demonstrating pneumomediastinum after cardiac radiofrequency catheter ablation for refractory atrial fibrillation.]] | [[File:PMC3631790 kjtcs-46-142-g003.png|thumb|Chest CT demonstrating pneumomediastinum after cardiac radiofrequency catheter ablation for refractory atrial fibrillation.]] | ||
*CT chest with contrast is the recommended modality, but repeat testing may be needed for eventual diagnosis <ref> Han H-C, Hui-Chen Han From the Austin Health, Ha FJ, et al. Atrioesophageal Fistula. Circulation: Arrhythmia and Electrophysiology. https://www.ahajournals.org/doi/full/10.1161/CIRCEP.117.005579. Published November 6, 2017. Accessed December 14, 2020. </ref> | *CT chest with contrast is the recommended modality, but repeat testing may be needed for eventual diagnosis <ref> Han H-C, Hui-Chen Han From the Austin Health, Ha FJ, et al. Atrioesophageal Fistula. Circulation: Arrhythmia and Electrophysiology. https://www.ahajournals.org/doi/full/10.1161/CIRCEP.117.005579. Published November 6, 2017. Accessed December 14, 2020. </ref> | ||
*Endoscopy may be considered, but may be associated an increased risk of clinical deterioration | *Endoscopy may be considered, but may be associated an increased risk of clinical deterioration | ||
*Transthoracic and transesophageal echocardiography have not been found to be highly sensitive | *Transthoracic and transesophageal echocardiography have not been found to be highly sensitive | ||
==Management== | ==Management== | ||
*Mortality is high in all patients | *Mortality is high in all patients | ||
*Surgery has the best mortality benefit, followed by endoscopic intervention | *Surgery has the best mortality benefit, followed by endoscopic intervention | ||
*Nonintervention has the worst outcome | *Nonintervention has the worst outcome | ||
==Disposition== | ==Disposition== | ||
*Admission | *Admission | ||
*Surgery consultation | *Surgery consultation | ||
==See Also== | ==See Also== | ||
==External Links== | ==External Links== | ||
==References== | ==References== | ||
<references/> | <references/> | ||
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[[Category:Cardiology]] | [[Category:Cardiology]] | ||
[[Category:GI]] | [[Category:GI]] | ||
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Revision as of 21:42, 4 January 2026
Background
- Rare but deadly complication of atrial ablation
- There have been reported cases with various ablation modalities (including radiofrequency ablation, cryoablation, high intensity focused ultrasound, and surgical ablation)
- Incidence is low (<0.1%) [1]
- Usually formed between esophagus and left atrium
- Thought to be related to adverse healing secondary to esophageal injury during the ablation procedure
Clinical Features
- Most common presenting symptoms:
- Fever
- Neurological symptoms (including focal neurological symptoms, seizure, AMS)
- Gastrointestinal symptoms (including hematemesis, melena, dysphagia, nausea/vomiting)
- Chest pain
- Most common time frame to presentation is 2-4 weeks post procedure but can occur up to 2 months post procedure
Differential Diagnosis
Chest pain
Critical
- Acute coronary syndromes (ACS)
- Aortic dissection
- Cardiac tamponade
- Coronary artery dissection
- Esophageal perforation (Boerhhaave's syndrome)
- Pulmonary embolism
- Tension pneumothorax
Emergent
- Cholecystitis
- Cocaine-associated chest pain
- Mediastinitis
- Myocardial rupture
- Myocarditis
- Pancreatitis
- Pericarditis
- Pneumothorax
Nonemergent
- Aortic stenosis
- Arthritis
- Asthma exacerbation
- Biliary colic
- Costochondritis
- Esophageal spasm
- Gastroesophageal reflux disease
- Herpes zoster / Postherpetic Neuralgia
- Hypertrophic cardiomyopathy
- Hyperventilation
- Mitral valve prolapse
- Panic attack
- Peptic ulcer disease
- Pleuritis
- Pneumomediastinum
- Pneumonia
- Rib fracture
- Stable angina
- Thoracic outlet syndrome
- Valvular heart disease
- Muscle sprain
- Psychologic / Somatic Chest Pain
- Spinal Root Compression
- Tumor
Evaluation
- CT chest with contrast is the recommended modality, but repeat testing may be needed for eventual diagnosis [2]
- Endoscopy may be considered, but may be associated an increased risk of clinical deterioration
- Transthoracic and transesophageal echocardiography have not been found to be highly sensitive
Management
- Mortality is high in all patients
- Surgery has the best mortality benefit, followed by endoscopic intervention
- Nonintervention has the worst outcome
Disposition
- Admission
- Surgery consultation
See Also
External Links
References
- ↑ Nair KK, Danon A, Valaparambil A, Koruth JS, Singh SM. Atrioesophageal Fistula: A Review. J Atr Fibrillation. 2015;8(3):1331. Published 2015 Oct 31. doi:10.4022/jafib.1331
- ↑ Han H-C, Hui-Chen Han From the Austin Health, Ha FJ, et al. Atrioesophageal Fistula. Circulation: Arrhythmia and Electrophysiology. https://www.ahajournals.org/doi/full/10.1161/CIRCEP.117.005579. Published November 6, 2017. Accessed December 14, 2020.