Atrioesophageal fistula after atrial fibrillation catheter ablation: A case report

Rationale:Atrioesophageal fistula (AEF) is a rare but serious complication of atrial fibrillation (AF) catheter ablation with associated high mortality rates.Patient concerns:A 42-year-old male patient who underwent catheter ablation in local hospital 20 days ago because of persistent AF was admitted to our Emergency Room with unconsciousness and high axillary temperature and white blood cell count. Craniocerebral CT scan found multiple infarct lesions in both frontal and occipital lobes. Pneumatosis between the left atrium and the esophagus was observed in the chest CT.Diagnoses:AEF.Interventions:We performed a salvage operation of the left atrium debridement, and left atrium patch repairing under extracorporeal circulation. We opened the mediastinum, and dissected the esophageal perforation. A special irrigating catheter with multiple side ports on the tip was placed from the esophagus to the posterior mediastinum through the esophageal orificium fistulae. We also inserted a gastrointestinal tube to the jejunum under gastroscopy. Three additional drainage tubes were inserted into the esophageal bed and the right thoracic cavity.Outcomes:The procedure was successful. But 7 days later, the patient''s family chose to forgo treatment due to multiple cerebral infarcts, respiratory and blood system infection, liver failure, and other complications.Lessons:AEF is a rare but fatal complication after catheter ablation. Heightened vigilance is required for early recognition of the AEF. Surgical treatment should be performed as early as possible, especially before the neurological complications occur.     

Combined management of esophagopericardial fistula sustained after catheter ablation for atrial fibrillation

Introduction: Radiofrequency ablation (RFA) is an effective treatment modality for atrial fibrillation (AF); however, serious complications can occur. We present the case of a highly morbid consequence, the esophagopericardial fistula (EPF). Case: A hemodynamically unstable patient with a history of AF and recent RFA presented with chest pain and was found to have pneumopericardium and pericardial effusion. The patient went to the operating room emergently for combined management with surgical pericardial window and endoscopic stent placement. Conclusion: EPF must be on the differential diagnosis while evaluating patients who develop constitutional symptoms or sudden onset chest pain days or weeks after catheter ablation for AF. Early detection followed by aggressive management with a combined surgical and endoscopic approach may be considered for successful treatment of this type of postablation esophageal perforation if an atrioesophageal fistula is effectively ruled out.     

Aorto-right atrial fistula following transseptal catheterization and catheter ablation for atrial fibrillation

Aorto-cameral fistula, either congenital or acquired, is an abnormal connection between the ascending aortic root and one of the cardiac chambers. We report a case of a 61-year-old male with history of atrial fibrillation and 2 radiofrequency ablation procedures, referred to us for surgical Cox Maze procedure. Preoperative cardiac computerized tomography revealed a fistulous connection between the aortic root and the right atrium. Later, the patient underwent successful surgical closure of the fistula during the Cox Maze procedure. In this paper, we also discuss the clinical presentation, natural history, anatomy of the interatrial septum, and management of aorto-cameral fistula.     

心房颤动导管消融后心房食管瘘的研究概况

心房颤动(房颤)是较常见的一种心律失常,目前导管消融作为其治疗手段之一,已广泛应用于临床。心房食管瘘是房颤导管消融术的一种罕见并发症,但却是最可怕和致命的。因此,为了能降低其发生的风险,我们需要充分认识该并发症,并采取积极有效的预防措施。本文综述了心房食管瘘的发病机制、危险因素、诊断及治疗,以及目前可能有效的一些预防措施,以期为临床提供参考。     

Time course of esophageal lesions after catheter ablation with cryothermal and radiofrequency ablation: implication for atrio-esophageal fistula formation after catheter ablation for atrial fibrillation

Background: Atrio-esophageal fistulas have been described as a consequence of radiofrequency (RF) ablation for the treatment of atrial fibrillation (AF). However, whether cryoablation can avoid this potential fatal complication remains unclear.
Methods and Results: We studied the effects of direct application of RF and cryoablation on the cervical esophagus in 16 calves. Cryoablation was performed with a 6.5-mm catheter probe using a single 5-minute freeze at <−80°C, and RF ablation was delivered with an 8-mm catheter electrode at 50 W and 50°C for 45–60 seconds. Histopathologic assessments were performed at 1, 4, 7, and 14 day(s) after completion of the ablation protocol: four animals were examined each day. A total of 85 direct esophageal ablations were performed: 41 with RF and 44 with cryoablation. There were no significant differences in lesion width, depth, or volume between cryoablation and RF ablation at Day 1, 4, and 14 after the procedure (P > 0.05). However, lesion width and volume were significantly larger with RF than with cryoablation at Day 7. Although acute (Day 1) and chronic (Day 14) RF and cryoablation lesions were of comparable size, histologic evidence of partial- to full-wall esophageal lesion ulceration was observed in 0 of 44 (0%) lesions with cryoablation, compared with 9 of 41 (22%) lesions with RF ablation (P = 0.0025).
Conclusions: Direct application of cryoablation and RF ablation created similar acute and chronic lesion dimensions on the esophagus. However, cryoablation was associated with a significantly lower risk of esophageal ulceration, compared with RF ablation.     

Reversal of pulmonary vein remodeling after catheter ablation of atrial fibrillation

Background Pulmonary veins (PV) and the atria undergo electrical and structural remodeling in atrial fibrillation (AF). This study aimed to determine PV and left atrial (LA) reverse remodeling after catheter ablation for AF assessed by chest computed tomography (CT). Methods PV electrophysiologic studies and catheter ablation were performed in 63 patients (68% male; mean ± SD age: 56 ± 10 years) with symptomatic AF (49% paroxysmal, 51% persistent). Chest CT was performed before and 3 months after catheter ablation. Results At baseline, patients with persistent AF had a greater LA volume (91 ± 29 cm³ vs. 66 ± 27 cm3; P = 0.003) and mean PV ostial area (241 ± 43 mm² vs. 212 ± 47 mm²; P = 0.03) than patients with paroxysmal AF. There was no significant correlation between the effective refractory period and the area of the left superior PV ostium. At 3 months of follow-up after ablation, 48 patients (76%) were AF free on or off antiar?rhythmic drugs. There was a significant reduction in LA volume (77 ± 31 cm³ to 70 ± 28 cm³; P < 0.001) and mean PV ostial area (224 ± 48 mm² to 182 ± 43 mm²; P < 0.001). Patients with persistent AF had more reduction in LA volume (11.8 ± 12.8 cm³ vs. 4.0 ± 11.2 cm³; P = 0.04) and PV ostial area (62 mm² vs. 34 mm²; P = 0.04) than those who have paroxysmal AF. The reduction of the averaged PV ostial area was significantly correlated with the reduction of LA volume (r = 0.38, P = 0.03). Conclusions Catheter ablation of AF improves structural remodeling of PV ostia and left atrium. This finding is more apparent in patients with persistent AF treated by catheter ablation.     

Evaluation of pulmonary vein stenosis after catheter ablation of atrial fibrillation

Pulmonary vein (PV) stenosis has emerged recently as an important issue in patients who received radiofrequency (RF) ablation of atrial fibrillation (AF). Serial pathophysiological responses, including thrombosis, metaplasia, proliferation and neovascularization, may lead to PV stenosis after RF energy application around or inside the PV ostia. The clinical manifestations of PV stenosis consist of chest pain, dyspnea, cough, hemoptysis, recurrent lung infection and pulmonary hypertension. Although PV stenosis can be asymptomatic, its severity may be related to the numbers of stenotic PVs, the degree and chronicity of PV stenosis. The incidence of PV stenosis (defined as luminal diameter reduction >50%) detected by spiral computer tomography scan or three dimensional magnetic resonance angiography was from 0 to 7% per PV after isolation of PVs from left atria. Furthermore, some patients may show late progression of PV stenosis during follow-up. The first choice of treatment for symptomatic PV stenosis is PV angioplasty with stenting; however, restenosis were reported occasionally. Several studies have analyzed the predictors of PV stenosis, and the results are controversial. However, the consensus for prevention of PV stenosis should include less energy application and the ablation site more close to the atrial site.     

Evaluation of the recurrence of atrial fibrillation after pulmonary venous ablation

OBJECTIVES: The mechanism of the recurrence of atrial fibrillation after pulmonary vein ablation was evaluated. METHODS: Eighty patients with atrial fibrillation underwent pulmonary vein ablation. If extrasystoles or atrial fibrillation initiations were frequent, focal ablation was performed at the site of the earliest activation. If the patient had little or no ectopy, all pulmonary veins with distinct and late pulmonary vein potentials were targeted for pulmonary vein isolation, which was achieved by minimal segmental ablation limited to the ostial site with the earliest pulmonary vein potentials. RESULTS: Focal ablation or pulmonary vein isolation was performed in 42 and 38 patients, respectively. After focal ablation, atrial fibrillation recurred in 23 patients and re-ablation was performed in 10:7 at sites near the previous source, 2 at a different part of the same pulmonary vein, and 1 at a different pulmonary vein. After pulmonary vein isolation, atrial fibrillation recurred in 19 patients and re-ablation was performed in 14:8 due to recovery of atrio-pulmonary vein conduction, 3 at non-pulmonary vein foci, 2 at pulmonary vein ostia proximal to the previous pulmonary vein isolation, and 1 at a different pulmonary vein. CONCLUSIONS: After focal ablation, atrial fibrillation recurred from other foci in the same pulmonary vein or other pulmonary veins. Therefore, three or four pulmonary veins should be isolated. However, atrial fibrillation recurred after pulmonary vein isolation due to the recovery of atrio-pulmonary vein conduction or non-pulmonary vein foci. Further development of new mapping and ablation systems to detect the foci and create a complete lesion at the pulmonary vein ostium may be necessary.     

心房颤动导管消融术后早期心力衰竭12例临床分析

目的:认识心房颤动(房颤)导管消融术的另一种并发症--急性心力衰竭(心衰).方法:回顾分析12例既往无心力衰竭史、因房颤经导管消融术后早期发生急性心衰患者的临床资料.结果:1 032例房颤导管消融术后48 h内发生急性心衰12例(1.2%),12例中慢性房颤11例,阵发性房颤1例.临床表现为呼吸急促12例(100%),其中端坐呼吸8例(67%),剧烈胸痛2例(17%),发热(37.5℃～38.5℃)6例(50%),肺部湿性啰音12例(100%),心室率增快12例(100%),低血压1例(8%),胸片提示胸腔积液3例(25%)、肺水肿改变4例(33%),经胸超声心动图提示少量心包积液5例(42%),白细胞计数大于10.0×109/L 7例(58%),左室射血分数(59.6±3.2)%.所有患者于治疗后2～7 d内临床症状消失.结论:房颤导管消融术后早期可能会发生心衰,合理的支持治疗可在短期内改善病情.     

Long-term follow-up after radiofrequency catheter ablation for atrial fibrillation

Aims: Data on long-term follow-up of patients who have undergone catheterablation for atrial fibrillation (AF) are very limited. Thisreport aimed at presenting clinical outcome and AF-free survivalafter pulmonary vein (PV) isolation over an extended (>3years) follow-up period. Methods and results: Thirty-nine patients subjected to PV isolation for paroxysmalAF were followed-up for at least 3 years according to a strictprotocol. Fourteen patients (35.8%) had one, 19 patients (50%)had two, and 6 patients (15.4%) had three ablation procedures.At end of follow-up (42.2 ± 6.0 months), 17 patients(43.5%) were completely free of AF or other atrial arrhythmia,and 26 patients (66.6%) had symptomatic improvement. The long-termsuccess rate was 21.4% for patients subjected to a single ablationprocedure, 52.6% for patients subjected to two catheter ablationprocedures, and 66.7% for patients who underwent three ablationprocedures (P = 0.094). There was also a trend for patientswho underwent a combination of different ablation procedures(ostial, antral, and/or circumferential) to have a higher AF-freesurvival when compared with patients subjected to the same procedure(P-value for log-rank test = 0.036). Conclusion: Catheter ablation does not eliminate paroxysmal AF in up to56% of patients in the long term, despite the use of two orthree ablation procedures in two-thirds of them. However, itconfers symptomatic improvement in 67% of treated patients.     

Cardiac injury after percutaneous catheter ablation for atrial fibrillation

Aims: Small elevations in troponin T levels have been shown with limitedradiofrequency (RF) ablation procedures for supraventriculartachycardia, usually to levels below the threshold for ischaemiaor infarction. Left atrial catheter ablation for atrial fibrillation(AF) requires far more RF energy, therefore could be expectedto have greater elevation in troponin T. We determined troponinT levels before and after ablation in these patients to evaluatethe amount of rise with this ablation. Methods: All patients undergoing pulmonary vein isolation (PVI) fromMay 2004 to October 2004 had troponin T levels measured 4 hfollowing completion of the procedure. The first 30 patientsalso had a troponin T level measured 1 h prior to PVI to establisha baseline reference. Results: Sixty patients were studied, with 81.7% males and a mean ageof 54.6 ± 9.9 years. No patient had underlying structuralheart disease. The baseline troponin T level was normal (<0.01µg/L) in all 30 patients. Post-procedure troponin T levelswere elevated in all 60 patients compared with baseline (P <0.05), with a mean level of 0.85 µg/L and a range of 0.26–1.57µg/L after an average RF ablation time of 56 ±15 min. All levels were above the reference range for diagnosisof acute myocardial infarction (>0.15 µg/L). TroponinT level was not related to the number of RF lesions, RF time,procedure time, or associated external cardioversion. Conclusions: Troponin T elevations occurred in all patients undergoing PVI,to levels at least 20 times the normal concentration, into therange for diagnosis of acute myocardial infarction. Therefore,troponin T would not be specific for ischaemia in the settingof chest pain post-catheter ablation for AF.     

Left atrial-esophageal fistula following radiofrequency catheter ablation of atrial fibrillation

This report describes a fatal case of left atrial-esophageal fistula occurring in a 72-year-old man after a radiofrequency catheter ablation of paroxysmal atrial fibrillation. Catheter ablation was performed around the pulmonary vein using an 8-mm-tip electrode (60 W or 55 degrees C) guided by a 25-mm circular catheter. On day 22 of follow-up, the patient presented with seizures followed by hematemesis due to left atrial-esophageal fistula. His clinical condition deteriorated, and he died of speticemia. Thus, left atrial-esophageal fistula is a sever complication of radiofrequency catheter ablation of the left atrial posterior wall.     

Asymptomatic pulmonary vein stenosis after cryoballoon catheter ablation of paroxysmal atrial fibrillation

Pulmonary vein (PV) isolation is an effective treatment option for symptomatic atrial fibrillation. PV stenosis is a well-recognized complication of radiofrequency energy application but has not been observed following cryoballoon ablation. Here, we report a case of asymptomatic PV stenosis associated with cryoballoon PV isolation, illustrating a risk that should be considered when applying this technique.     

Acquired pulmonary vein stenosis after radiofrequency catheter ablation of paroxysmal atrial fibrillation

INTRODUCTION: Elimination of the initiating focus within the pulmonary vein (PV) using radiofrequency (RF) catheter ablation is a new treatment modality for treatment of drug-refractory atrial fibrillation. However, information on the long-term safety of RF ablation within the PV is limited. METHODS AND RESULTS: In 102 patients with drug-refractory atrial fibrillation and at least one initiating focus from the PV, series transesophageal echocardiography was performed to monitor the effect of RF ablation on the PV. There were 66 foci in the right upper PV and 65 foci in the left upper PV. Within 3 days of ablation, 26 of the ablated right upper PVs (39%) had increased peak Doppler flow velocity (mean 130+/-28 cm/sec, range 106 to 220), and 15 of the ablated left upper PVs (23%) had increased peak Doppler flow velocity (mean 140+/-39 cm/sec, range 105 to 219). Seven patients had increased peak Doppler flow velocity in both upper PVs. No factor (including age, sex, site of ablation, number of RF pulses, pulse duration, and temperature) could predict PV stenosis after RF ablation. Three patients with stenosis of both upper PVs experienced mild dyspnea on exertion, but only one had mild increase of pulmonary pressure. There was no significant change of peak and mean flow velocity and of PV diameter in sequential follow-up studies up to 16 (209+/-94 days) months. CONCLUSION: Focal PV stenosis is observed frequently after RF catheter ablation applied within the vein, but usually is without clinical significance. However, ablation within multiple PVs might cause pulmonary hypertension and should be considered a limiting factor in this procedure.