Neurological consequences of atrioesophageal fistula after radiofrequency ablation in atrial fibrillation.

BACKGROUND

Radiofrequency ablation for atrial fibrillation (RAF) is an increasingly performed procedure. It is performed during cardiac surgery or percutaneously by catheter. A dangerous complication of RAF is atrioesophageal fistula (AEF), which predominantly manifests neurologically owing to food embolism. Because neurologists may not be familiar with AEF and the prognosis is dependent on a prompt diagnosis, awareness of AEF by the neurologist may play a crucial role.

OBJECTIVE

To summarize for the neurologist the knowledge about fistula between the left atrium and esophagus occurring after RAF.

DESIGN, SETTING, AND PATIENTS: Using a MEDLINE search, we collected reports about AEF after RAF in 28 patients.

MAIN OUTCOME MEASURES: From the collected reports, the description of symptoms, diagnostic investigations, therapy, and outcome of the 28 patients were summarized.

RESULTS

In 28 cases, AEF developed 3 to 38 days after RAF. Confusion, grand mal seizures, meningitis, focal cortical signs, and postprandial transient ischemic attacks associated with fever were the leading manifestations in 21 of 28 patients. Blood tests showed leukocytosis, elevated serum C-reactive protein levels, and thrombocytopenia. Blood cultures were frequently positive for bacteria. Lumbar puncture revealed pleocytosis, elevated protein levels, increased lactate levels, and bacteria. Diagnosis was established by thoracic contrast computed tomography. Endoscopy, insertion of nasogastric tubes, and transesophageal echocardiography were detrimental, leading to an increase in fistula size and food or air embolism. Therapy comprised surgery (n = 11) or temporary esophageal stenting (n = 1). The remaining patients died before attempted surgery or confirmation of the diagnosis. A neurological deficit persisted in 3 of the 9 surviving patients.

CONCLUSIONS

In patients with meningitis, stroke, seizures, or impaired consciousness and fever, it should be determined whether they have had a previous RAF. In cases with a history of recent RAF, AEF should be strongly considered, especially if there are also symptoms such as dysphagia or chest pain. After RAF, the patient, his or her family, and his or her treating physicians should be informed about the signs of AEF, which may occur even weeks after RAF.