Neurological manifestations of atrio-esophageal fistulas from left atrial ablation

Left atrial ablation (LAAB) is carried out as an alternative treatment of atrial fibrillation refractory to conservative measures. An increasingly recognized complication of LAAB is an atrio-esophageal fistula (AEF). Neurological manifestations usually dominate the presentation of an AEF and result from cardiac embolism of thrombi, transgressed esophageal contents, or air. AEFs have been reported after LAAB in 52 patients (23 men, age 35-76 years), described in 24 publications, so far. AEFs manifest clinically on the average 17 days (3-38 days) after ablation. Neurological manifestations include embolic strokes (n = 30), seizures (n = 9), transitory-ischaemic attacks (n = 6), coma (n = 6), or psychiatric abnormalities (n = 5). Imaging studies of the cerebrum most frequently show multiple embolic strokes or air embolism. The diagnosis is made upon thoracic computed tomography with contrast media. An act of swallowing, trans-esophageal echocardiography, gastroscopy, or esophageal stenting must be avoided not to enlarge the shunt. The only expedient therapy is surgical closure of the fistula, but even then, the prognosis is poor with a mortality of 71%. AEFs should be suspected if there is a history of LAAB followed by fever, thoracic pain, postprandial cerebral strokes, seizures, coma, or confusion with a latency of days to 5 weeks after ablation. Diagnostic work-up must avoid measures, which enlarge the fistula. Treatment is surgical exclusively.