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• W2034230932 abstract "Left atrial-esophageal fistula is a highly lethal complication of ablative therapy for atrial fibrillation. Because of its unusual rate of occurrence, there has not been a uniform approach to either the diagnosis or corrective therapy. We offer 1 such surgical option based on presumptive and early diagnosis—left atrial repair with cardiopulmonary bypass followed by repair of the esophagus with an omental wrap and supported with decompressive gastrostomy and feeding jejunostomy. Left atrial-esophageal fistula is a highly lethal complication of ablative therapy for atrial fibrillation. Because of its unusual rate of occurrence, there has not been a uniform approach to either the diagnosis or corrective therapy. We offer 1 such surgical option based on presumptive and early diagnosis—left atrial repair with cardiopulmonary bypass followed by repair of the esophagus with an omental wrap and supported with decompressive gastrostomy and feeding jejunostomy. Atrial-esophageal fistula is an infrequent but reported complication of catheter and surgical radiofrequency ablation. Estimated incidence is 1 in 10,000 to 2 in 1000 in the medical literature [1Dagres N. Hindricks G. Kottkamp H. et al.Complications of atrial fibrillation ablation in a high-volume center in 1000 procedures: still cause for concern?.J Cardiovasc Electrophysiol. 2009; 20: 1014-1019Crossref PubMed Scopus (250) Google Scholar], with rates of 1 in 100 in a series of surgical ablations [2Cappato R. Calkins H. Chen S.A. et al.Prevalence and causes of fatal outcome in catheter ablation of atrial fibrillation.J Am Coll Cardiol. 2009; 53: 1798-1803Abstract Full Text Full Text PDF PubMed Scopus (472) Google Scholar]. Ghia and colleagues [3Ghia K.K. et al.A nationwide survey on the prevalence of atrioesophageal fistula after left atrial radiofrequency catheter ablation.J Interventional Cardiology Electrophysiolo. 2009; 24: 33-36Crossref PubMed Scopus (161) Google Scholar] reported on a nationwide survey of the Heart Rhythm Society in the United States for an incidence of 0.03% [3Ghia K.K. et al.A nationwide survey on the prevalence of atrioesophageal fistula after left atrial radiofrequency catheter ablation.J Interventional Cardiology Electrophysiolo. 2009; 24: 33-36Crossref PubMed Scopus (161) Google Scholar]. Tamponade was a more frequently reported complication in a catheter-based series [4Siegel M.O. Parenti D.M. Simon G.L. Atrial-Esophageal Fistula after Atrial Radiofrequency Catheter Ablation.Clinical Infectious Diseases. 2010; 51: 73-76Crossref PubMed Scopus (38) Google Scholar]. Atrial-esophageal fistulas after catheter ablation have been highly fatal, despite aggressive surgical approaches. The Cleveland Clinic reported 9 cases in 10 years, with 100% mortality for this complication [5Cummings J.E. et al.Brief Communication: Atrial-Esophageal Fistulas after Radiofrequency Ablation.Annals of Internal Medicine. 2006; 144: 572-574Crossref PubMed Scopus (188) Google Scholar]. There have been isolated reports of survivors after operation, but overall mortality has been reported to be about 80%, with most survivors having significant permanent neurologic deficits [3Ghia K.K. et al.A nationwide survey on the prevalence of atrioesophageal fistula after left atrial radiofrequency catheter ablation.J Interventional Cardiology Electrophysiolo. 2009; 24: 33-36Crossref PubMed Scopus (161) Google Scholar]. Mechanisms of injury have included energy source, high energy settings, and unipolar ablation versus bipolar ablation in the presence of a transesophageal echocardiography probe. Faced with a similar complication, we embarked on a surgical repair that we believe is unique and recognizes the critical concept that esophageal intraluminal pressures tend to be higher than left atrial pressures during retching, vomiting, and coughing, resulting in food, bacteria, and air entering the heart and causing embolization to the brain. One hypothesis about the air emboli is that the esophagus has the capability to develop pressure 10 times greater than intraatrial pressure. Although the left atrial pressure is higher at rest, exsanguination from atrial-esophageal fistula is uncommon because resistance to flow across the fistula is high. Success in salvaging these critically ill patients rests with early closure of the left atrial communication before any surgical manipulation of the esophagus. The ability to heal an esophageal repair as well as a left atrial repair hinges on the use of a greater omentum pedicle mobilized in a way that it is interposed between the 2 structures and wrapped around the esophagus. A 62-year-old physician with a history of intermittent atrial fibrillation had undergone catheter ablation 1 month previously. He had described several days of odynophagia. A sudden onset of fever, chills, and rigors had developed. Several hours later he had a syncopal episode. The patient was taken to the emergency room where he was found to be hypotensive and febrile. During the emergency room stay, ST elevations were seen inferiorly on electrocardiography. Cardiac catheterization was performed, revealing nonobstructed coronary arteries and a normal ejection fraction. The patient was transferred to our facility, where on admission he complained of abdominal pain and nausea. While being interviewed by the attending admitting physician, the patient vomited and shortly afterward a left hemiplegia developed followed shortly by a grand mal seizure. The patient was intubated for airway protection. A 4-vessel cerebral angiogram was obtained and was entirely normal. Computed tomography (CT) of the chest revealed some minor inflammatory thickening of the mediastinum to the right of the midline around the esophagus. No other salient findings were noted on CT. The transthoracic echocardiogram was interpreted as normal. Blood cultures were positive for gram-positive Streptococcus. It was assumed that there was a left atrial-esophageal fistula, with the ST elevations and neurologic findings secondary to air embolism. Because there were already serious consequences from air embolism, our surgical strategy was based on immediate interruption of the fistula on the left atrial side followed by approaching the esophageal pathologic condition. It was instructive that the neurologic events that were witnessed had occurred immediately after the retching and vomiting, clearly implicating elevated intraluminal esophageal pressures as the driving force for the air embolism. The strategy was to enable closure of the left atrial communication as a priority. It was believed that this would be best accomplished through a standard sternotomy incision and left atriotomy using cardiopulmonary bypass, despite the fact there were recent neurologic changes. The advantage of this approach was the ability to clearly visualize the left atrial fistula communication occurring in the posterior aspect of the atrium, having entered the atrium anterior to the pulmonary veins. Closure of the left atrial communication from inside the atrium allowed the placement of suture material in an environment bathed in blood, and it is more forgiving as it relates to potential long-term infectious complications. Entering the left atrium through the uninvolved atrium, using bypass, allowed for easy localization and avoided further embolization, which would occur if one were to approach at the site of the fistula and mobilize the esophagus. With this procedure completed during a relatively short pump run, the sternum and soft tissue were closed and attention was turned toward mobilizing the greater omentum through a separate supraumbilical incision, basing the omental pedicle on the right gastroepiploic artery. This was freed from the greater curvature of the stomach as well as the transverse colon, with sufficient length to be passed through a diaphragmatic aperture into the right side of the chest. A Stamm gastrostomy and Witzel jejunostomy were performed to allow for gastric decompression as well for as the potential for long-term enteral nutrition support. With the abdomen closed, the patient was prepared for a right thoracotomy. The esophagus was encircled and mobilized to the level of the left atrium. Densely adherent, it was separated by sharp dissection. A dime-sized esophageal communication was clearly demarcated and closed with inverted interrupted silk sutures. The mediastinum was drained extensively. The pedicled omental flap was then interposed between the esophagus and left atrium and wrapped around the esophagus at the level of the repair. Jejunostomy feedings were initiated postoperative day 1. Postoperatively, the hemiplegia completely resolved and head CT was normal. The esophagogram 1 week postoperatively was normal, at which point oral feeding was initiated. A peripherally inserted central catheter was placed for antibiotic administration, which was to be of 6 weeks' duration. Atrial fibrillation was intermittent, and warfarin was restarted. The patient was discharged home 2 weeks after admission. Atrial-esophageal fistula caused by diffusion of ablative energy through the left atrial wall to the esophagus (because of the absence of pericardium and fat posteriorly) is lethal if not treated surgically. In reviewing the existing literature, it is clear that widespread gaseous or septic embolization will continue without prompt surgical intervention. Proceeding with surgical intervention is necessary based on clinical suspicion in the setting of recent atrial ablation, despite the fact that there may not be a specific diagnostic test that clearly demonstrates the pathologic condition. Rapid deterioration, neurologic damage, and death ensue with any delays in surgical intervention. Pursuing diagnostic testing delays therapy and in the case of endoscopy and transesophageal echocardiography may contribute to mortality. Anatomic studies of the left atrium and esophagus reveal both to be very thin walled, less than 5 mm thick. The esophagus is in direct contact with the posterior left atrium for more than 5 cm along its long axis. The transverse extent of contact between the esophagus and the posterior left atrium is 10 to 15 mm [6Lemola K. et al.Computed Tomographic Analysis of the Anatomy of the Left Atrium and the Esophagus: Implications for Left Atrial Catheter Ablation.Circulation. 2004; 110: 3655-3660Crossref PubMed Scopus (234) Google Scholar]. Ablation procedural precautions have focused on several factors: avoiding overlapping ablation lines, limiting generator settings to 50 W, and monitoring esophageal temperatures greater than 55°C [7Sonmez B. et al.A Fatal Complication Due to Radiofrequency Ablation for Atrial Fibrillation: Atrio-Esophageal Fistula.Ann Thorac Surg. 2003; 76: 281-283Abstract Full Text Full Text PDF PubMed Scopus (122) Google Scholar]. Cryoablation preserves the collagen structure of the tissue and may be less likely to disrupt the integrity of the atrial and esophageal walls [6Lemola K. et al.Computed Tomographic Analysis of the Anatomy of the Left Atrium and the Esophagus: Implications for Left Atrial Catheter Ablation.Circulation. 2004; 110: 3655-3660Crossref PubMed Scopus (234) Google Scholar]. Through January 2004, there were 3 reported cases of catheter ablation–related atrial esophageal fistulas [7Sonmez B. et al.A Fatal Complication Due to Radiofrequency Ablation for Atrial Fibrillation: Atrio-Esophageal Fistula.Ann Thorac Surg. 2003; 76: 281-283Abstract Full Text Full Text PDF PubMed Scopus (122) Google Scholar, 8Pappone Carlo et al.Atrio-Esophageal Fistula as a Complication of Percutaneous Transcatheter Ablation of Atrial Fibrillation.Circulation. 2004; 109: 2724-2726Crossref PubMed Scopus (758) Google Scholar, 9Scanavacca Mauricio et al.Left Atrial-Esophageal Fistual Following Radiofrequency Catheter Ablation of Atrial Fibrillation.Journal of Cardiovascular Electrophysiology. 2004; 15: 960-962Crossref PubMed Scopus (260) Google Scholar]. As of April 2006, 9 additional patients had been reported [5Cummings J.E. et al.Brief Communication: Atrial-Esophageal Fistulas after Radiofrequency Ablation.Annals of Internal Medicine. 2006; 144: 572-574Crossref PubMed Scopus (188) Google Scholar]. The last 9 cases were coordinated through the Cleveland Clinic Atrial Fibrillation database. Patients presented a mean of 12.3 days (10–16 days) after their ablations. Blood cultures revealed multiple bacterial species, including group A Streptococcus, Micrococcus, and Candida albicans. Patient symptoms began with malaise and fever. All patients had septic shock and cardiovascular collapse. This dichotomy of indolent and insidious presentation, followed rapidly by catastrophic collapse and neurologic symptoms of embolic stroke, is typical. In these 12 reports, there was 1 survivor with permanent neurologic deficits. It appears that although this is a rare complication, it is highly fatal. Rapid diagnosis and surgical correction are the only options. Fever, malaise, dysphagia, and neurologic symptoms in the setting of recent catheter ablation should always raise the possibility of atrial-esophageal fistula. Most of the patients in these reported series presented to either their primary care physicians or emergency rooms. Awareness and education of these physicians about the consideration of this diagnosis in any patient having an ablation within several weeks to a month is imperative. Surgical procedures have varied, consisting of esophageal ligation and decompression [10St. Julien Jamii et al.Successful Treatment of Atrioesophageal Fistula by Cervical Esophageal Ligation and Decompression.Annals of Thoracic Surgery. 2011; 91: 85-86Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar], esophageal stenting, and direct intracardiac or transthoracic repair with or without cardiopulmonary bypass [11Cazavet A. et al.Successful surgery for atrioesophageal fistula caused by transcatheter ablation of atrial fibrillation.J Thorac Cardiovasc. 2010; 140: 43-45Abstract Full Text Full Text PDF Scopus (32) Google Scholar, 12Bunch T.J. Nelson J. Foley T. et al.Temporary esophageal stenting allows healing of esophageal perforations following atrial fibrillation ablation procedures.J Cardiovasc Electrophysiol. 2006; 17: 435-439Crossref PubMed Scopus (114) Google Scholar, 13Khandhar S. Nitzache S. Ad N. Left atrioesophageal fistula following catheter ablation for atrial fibrillation: off-bypass, primary repair using an extrapericardial approach.J Thorac Cardiovasc Surg. 2010; 139: 507-509Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar]. Esophageal stenting is fraught with issues inherent to esophageal manipulation associated with persistent fistula and migration. Transthoracic repair and indirect techniques have been advocated, but the results are few, and it is difficult to draw conclusions. The reports have been remarkable for prolonged hospitalizations as well as persistent neurologic sequelae. Our approach advocates direct suture repair of the left atrium with cardiopulmonary bypass, which prioritizes the elimination of the gaseous and bacteremic contamination. The suture closure environment from within the left atrium contributes to a locally aseptic, blood-rich, and tissue-friendly milieu that allows for successful repair." @default.
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• W2034230932 title "Surgical Repair of a Left Atrial-Esophageal Fistula After Radiofrequency Catheter Ablation for Atrial Fibrillation" @default.
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