Putting the Pieces Together: Not Your Typical Cardiac Arrest

Abstract

INTRODUCTION: Atrioesophageal fistula (AEF) is an uncommon (0.15 per 1000 patients) complication following catheter ablation for atrial fibrillation. Though rare, prompt recognition is critical as unrecognized AEF formation is nearly always fatal and in the absence of death, catastrophic morbidity remains. CASE PRESENTATION: A 58-year-old Caucasian male with atrial fibrillation on rivaroxaban presented with chest pain. The patient had paroxysmal hematemesis and was intubated. He then developed cardiac arrest. Following successful ACLS, the patient was transferred to our tertiary care center for definitive care. Upon arrival, the patient was encephalopathic with intact cough, corneal and pupillary reflexes. Initial management focused on the hematemesis, secondary anemia, cardiac arrest and fever. Within the first several hours there was interval development of dysconjugate gaze and pupillary asymmetry. Unenhanced CT Head revealed pneumocephalus and a left cerebellar hemorrhage. MRI confirmed septic emboli. No clear unifying etiology accounted for the chest pain, hematemesis, cardiac arrest, encephalopathy, fever, pneumocephalus, intracranial hemorrhage and septic shock until the patient's local electrophysiologist called with concern as the patient was treated with radio frequency ablation (RFA) 17 days prior for atrial fibrillation. The diagnosis of AEF was highly suspected. A CT angiogram of the chest revealed a 5 mm posterior left atrial diverticulum consistent with AEF. The patient underwent surgical repair but never regained consciousness following multiple embolic strokes. The patient's family withdraw care. DISCUSSION: A fistula between the left atrium and esophagus may lead to severe bleeding and food or air emboli. The true incidence of AEF following RFA is unknown. One recent survey reported 6 cases AEF out of 20,425 procedures performed. All six patients developed cerebrovascular accidents; ultimately 5 of 6 died. Whereas another recent survey reported 7 cases AEF out of 45,115 procedures; 5 of 7 died. A recent review found 28 case reports of AEF following RFA. Symptoms developed 3 to 38 days after ablation. The leading symptoms reported included confusion, seizures, postprandial TIAs and bacteremia with septic emboli. CONCLUSIONS: The recognition of a unifying diagnosis for these eclectic mix of symptoms is critical for early surgical intervention.