Atrio-esophageal Fistula Secondary to Atrial Fibrillation Ablation: A Case Report

An atrio-esophageal fistula is an exceedingly rare but devastating complication of atrial fibrillation (AF) ablation procedures. Delays to diagnosis and definitive treatment herald a poor prognosis, with the development of catastrophic neurological injury or death secondary to cerebral air emboli. A high level of suspicion is essential to improve recognition of this rare but devastating condition.

A 59-year-old man presented to the emergency department with an acute stroke and reduced consciousness. This presentation was preceded by an uncomplicated AF ablation 19 days prior and a subsequent emergency department attendance within a few days of his procedure, where he had presented with a history of new chest pain and reflux symptoms. Imaging revealed intra-cranial and intra-cardiac air, which was attributed to an uncontrolled atrio-esophageal fistula. Treatment options were limited by the patient's clinical instability and the patient was eventually palliated after developing catastrophic brain injury due to extensive cerebral air emboli. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Patients typically first present to the emergency department with new symptoms of either gastroesophageal reflux or chest pain, therefore, early recognition by emergency physicians is vital. Characteristic symptoms alongside a recent history of a cardiac ablation procedure should prompt additional diagnostic imaging to look for evidence of an atrio-esophageal fistula.