Cardiovascular Pathology xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Cardiovascular Pathology
Case Report
A fatal case of atrioesophageal fistula following radiofrequency ablation of left atrium and pulmonary veins for atrial fibrillation W.R.A.S. Rajapaksha a,⁎, Kristopher S. Cunningham b, Toby H. Rose a, 1 a b
Department of Laboratory Medicine and Pathobiology, Faculty of Medicine, University of Toronto, and Provincial Forensic Pathology Unit, 25 Morton Shulman Avenue, Toronto, Ontario M3M 0B1 Canada Queen’s University, Kingston, Ontario, Canada
a r t i c l e
i n f o
Article history: Received 23 December 2013 Received in revised form 24 February 2014 Accepted 25 February 2014 Available online xxxx Keywords: Atrioesophageal fistula Radiofrequency ablation Atrial fibrillation
a b s t r a c t Atrial fibrillation (AF) is associated with significant morbidity and mortality. Hemodynamic compromise and formation of thrombi within the fibrillating atrium or atrial appendage can occur. Surgical treatment aims to eliminate dysrhythmia-triggering foci in the pulmonary veins and posterior left atrium by radiofrequency ablation techniques using ohmic heat. As medical treatment may be ineffective, radiofrequency catheter ablation is increasingly being used by interventional cardiac electrophysiologists for AF. Serious complications have been observed among patients who have undergone radiofrequency ablation, atrioesophageal fistula being a very rare example. This case describes a 43-year-old man who died after the development of an atrioesophageal fistula following radiofrequency ablation of the left atrium and pulmonary veins for treatment of AF. © 2014 Elsevier Inc. All rights reserved.
1. Introduction Atrial fibrillation (AF), the commonest form of cardiac dysrhythmia [1,2], requires a trigger for initiation. Most episodes are thought to be triggered within the pulmonary veins (PVs) and atrial appendage. Isolation of those foci and modification of the myocardium through selective scarring are the bases of treatment by radiofrequency ablation techniques using ohmic heat [3]. Left atrioesophageal fistula is a rare, potentially fatal complication of the radiofrequency ablation technique [4]. We describe a 43-year-old man who died from a left atrioesophageal fistula following radiofrequency ablation of the left atrium (LA) and PVs for the treatment of AF. 2. Case report A 43-year-old man with a 3-year history of AF was treated with radiofrequency ablation of the LA and PVs after failure of medical treatment with antiarrhythmic, anticoagulant, and antihypertensive drugs. He presented with palpitations; echocardiogram revealed a massive left atrium. Several unsuccessful attempts were made at transvenous coronary sinus cannulation. Circumferential PV ablation was then performed by transseptal puncture of the
Funding: none. ⁎ Corresponding author. Tel.: +1 647 329 1911/647 680 2457. E-mail addresses: [email protected] (W.R.A.S. Rajapaksha), [email protected] (K.S. Cunningham), [email protected] (T.H. Rose). 1 Tel.: +1 416 314 4040.
interatrial septum. About a month later, he presented to a second hospital complaining of pain in the throat and chest, as well as dyspnea and palpitations. He was examined, diagnosed with AF, and discharged with changes to his medications. The next day, he presented to a third hospital after a fall at home, which resulted in a scalp laceration. He also complained of nausea, coughing up bloodtinged sputum, and right arm weakness. Uncontrolled AF as well as deviation of his eyes to the right was noted. A computed tomographic scan of the head revealed no intracranial pathology. Significant hematemesis commenced while in the emergency department, followed shortly by cardiac arrest and death. At postmortem examination, there were two lacerations on the occipital scalp, without underlying injury to the skull or brain. The pericardium appeared normal, but contained approximately 30 ml of serosanguineous fluid. The heart was enlarged with a weight of 500 g. The LA and both ventricles were dilated. The mediastinal soft tissue was congested and firm. The left atrial wall was adherent to the esophagus over an area of 2×2 cm, located inferior to the carina (Fig. 1). A fistula with a 9-mm diameter connected the midposterior wall of the LA, centered between the four PV ostia, to the midanterior wall of the esophagus (Fig. 2). Diffuse endocardial fibrosis was observed on the posterior wall of the LA, also centered between the PV ostia. Approximately 500 ml of blood was present in the stomach. Microscopically, the posterior wall of the LA showed coagulative necrosis of the myocardium and epicardial fat with organizing granulation tissue away from the fistulous tract (Fig. 3). There was mild subendocardial fibrosis adjacent to the involved myocardium. The anterior esophageal wall appeared unremarkable away from the fistula.
1054-8807/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.carpath.2014.02.004
Please cite this article as: Rajapaksha WRAS, et al, A fatal case of atrioesophageal fistula following radiofrequency ablation of left atrium and pulmonary veins for atrial fibrillation, Cardiovasc Pathol (2014), http://dx.doi.org/10.1016/j.carpath.2014.02.004
2
WRAS. Rajapaksha et al. / Cardiovascular Pathology xxx (2014) xxx–xxx
Fig. 1. Heart in relation to opened esophagus and stomach.
3. Discussion Cardiac dysrhythmias are a group of heterogeneous conditions due to abnormal electrical activity in the heart. AF, the most common, is associated with significant morbidity and mortality [1,2]. AF can be considered as chaotic, asynchronous electrical activity in atrial tissue and may be associated with contractile and structural remodeling. The two major complications of AF are hemodynamic compromise, the result of loss of the atrial contribution to ventricular filling, and formation of thrombi within the fibrillating atrium or atrial appendage [2,3]. Thrombi can embolize systemically to the brain and other major organs, causing downstream ischemia with consequent morbidity or possibly death [2]. AF requires an initiating trigger; most episodes are triggered within the PVs. Pharmacological therapy to restore and maintain sinus rhythm in patients with AF may be unsuccessful and dangerous. Elimination of trigger foci and modification of the myocardium through selective scarring are the bases of treatment by radiofrequency ablation techniques using ohmic heat [3]. Radiofrequency catheter ablation of the distal PVs and posterior LA is increasingly being used by interventional cardiac electrophysiologists to treat patients with AF [3–5]. Complications observed in patients who have undergone radiofrequency ablation [3] (Table 1) include endocardial charring, PV
Fig. 3. Photograph of whole-mount section of fistula in relation to esophagus and LA.
dissection, and atrial or PV perforation. Severe bradydysrhythmias can occur during the procedure due to stimulation of vagal nerve fibers within the walls of the PVs. Milder complications include small pleural or pericardial effusions. Small transient atrial septal defects and hemodynamically insignificant PV stenosis can also be seen. Fistulas may be congenital or acquired. Acquired fistulas usually result from injury or surgery; they can also result from infection or inflammation. Because of tissue damage to the LA and the nearby esophagus during radiofrequency ablation, a fistula may form to any nearby anatomical structure during the healing and remodeling process in up to 1% of cases [4]. Although intraatrial pressure is relatively low compared to ventricular pressure, a pressure gradient exists between the LA and the esophageal lumen. A significant quantity of blood can pass through a fistula into the esophagus and then into more distal portions of the gastrointestinal (GI) tract. This man’s neurologic findings shortly before death may be explained by air embolization through the fistula into the LA and ultimately into the cerebrovascular circulation. The history of hematemesis and the presence of blood in the stomach would indicate bleeding from the atrium, through the fistula, and into the GI tract. Therefore, the cause of death was given as upper GI hemorrhage due to a left atrioesophageal fistula, complicating radiofrequency ablation for the treatment of paroxysmal atrial fibrillation. In conclusion, left atrioesophageal fistula due to radiofrequency ablation for the treatment of AF is a rare, fatal condition. In the case of symptoms suggestive of this diagnosis, prompt treatment might be life saving.
Table 1 Serious adverse effects
Fig. 2. Closer view of fistula between LA and anterior wall of esophagus.
1
Chest discomfort
2 3 4 5 6 7 8 9 10 11 12 13 14
Pericardial effusion/tamponade Pneumothorax Hemothorax Permanent diaphragmatic paralysis Valve damage Sepsis, abscess, or endocarditis Atrial flutter/tachycardia Transient ischemic attack Stroke PV stenosis Arteriovenous fistula Atrioesophageal fistula Death
Please cite this article as: Rajapaksha WRAS, et al, A fatal case of atrioesophageal fistula following radiofrequency ablation of left atrium and pulmonary veins for atrial fibrillation, Cardiovasc Pathol (2014), http://dx.doi.org/10.1016/j.carpath.2014.02.004
WRAS. Rajapaksha et al. / Cardiovascular Pathology xxx (2014) xxx–xxx
3.1. Key points - Atrial fibrillation, the most common cardiac dysrhythmia, is associated with significant morbidity and mortality. - Radiofrequency catheter ablation of the distal PVs and posterior LA is increasingly being used. - Atrioesophageal fistula due to radio frequency ablation for AF is a rare, fatal complication.
4. Summary This case report illustrates the death of a 43-year-old man who developed a left atrioesophageal fistula following radiofre-
3
quency ablation of the LA and PVs for the treatment of atrial fibrillation. References [1] Keshishian J, Young J, Hill E, Saloum Y, Brady PG. Esophageal injury following radiofrequency ablation for atrial fibrillation: injury classification. Gastroenterol Hepatol 2012;8:411–4. [2] Gutierrez C, Blanchard DG. Atrial fibrillation: diagnosis and treatment. Am Fam Physician 2011;83(1):61–8. [3] Nielsen JC, et al. Radiofrequency ablation as initial therapy in paroxysmal atrial fibrillation. N Engl J Med 2012;367:1587–95. [4] Sause, et al. Limiting esophageal temperature in radiofrequency ablation of left atrialtachyarrhythmias results in low incidence of thermal esophageal lesions. BMC Cardiovasc Disord 2010;10:52. [5] Gokdeniz T, Aykan AC, Yildiz M, Celik S. Transvenous radiofrequency ablation therapy in the treatment of arrhythmias: a single center experience. Kosuyolu Kalp Derg 2013;16(1):36–41.
Please cite this article as: Rajapaksha WRAS, et al, A fatal case of atrioesophageal fistula following radiofrequency ablation of left atrium and pulmonary veins for atrial fibrillation, Cardiovasc Pathol (2014), http://dx.doi.org/10.1016/j.carpath.2014.02.004
Contents lists available at ScienceDirect
Cardiovascular Pathology
Case Report
A fatal case of atrioesophageal fistula following radiofrequency ablation of left atrium and pulmonary veins for atrial fibrillation W.R.A.S. Rajapaksha a,⁎, Kristopher S. Cunningham b, Toby H. Rose a, 1 a b
Department of Laboratory Medicine and Pathobiology, Faculty of Medicine, University of Toronto, and Provincial Forensic Pathology Unit, 25 Morton Shulman Avenue, Toronto, Ontario M3M 0B1 Canada Queen’s University, Kingston, Ontario, Canada
a r t i c l e
i n f o
Article history: Received 23 December 2013 Received in revised form 24 February 2014 Accepted 25 February 2014 Available online xxxx Keywords: Atrioesophageal fistula Radiofrequency ablation Atrial fibrillation
a b s t r a c t Atrial fibrillation (AF) is associated with significant morbidity and mortality. Hemodynamic compromise and formation of thrombi within the fibrillating atrium or atrial appendage can occur. Surgical treatment aims to eliminate dysrhythmia-triggering foci in the pulmonary veins and posterior left atrium by radiofrequency ablation techniques using ohmic heat. As medical treatment may be ineffective, radiofrequency catheter ablation is increasingly being used by interventional cardiac electrophysiologists for AF. Serious complications have been observed among patients who have undergone radiofrequency ablation, atrioesophageal fistula being a very rare example. This case describes a 43-year-old man who died after the development of an atrioesophageal fistula following radiofrequency ablation of the left atrium and pulmonary veins for treatment of AF. © 2014 Elsevier Inc. All rights reserved.
1. Introduction Atrial fibrillation (AF), the commonest form of cardiac dysrhythmia [1,2], requires a trigger for initiation. Most episodes are thought to be triggered within the pulmonary veins (PVs) and atrial appendage. Isolation of those foci and modification of the myocardium through selective scarring are the bases of treatment by radiofrequency ablation techniques using ohmic heat [3]. Left atrioesophageal fistula is a rare, potentially fatal complication of the radiofrequency ablation technique [4]. We describe a 43-year-old man who died from a left atrioesophageal fistula following radiofrequency ablation of the left atrium (LA) and PVs for the treatment of AF. 2. Case report A 43-year-old man with a 3-year history of AF was treated with radiofrequency ablation of the LA and PVs after failure of medical treatment with antiarrhythmic, anticoagulant, and antihypertensive drugs. He presented with palpitations; echocardiogram revealed a massive left atrium. Several unsuccessful attempts were made at transvenous coronary sinus cannulation. Circumferential PV ablation was then performed by transseptal puncture of the
Funding: none. ⁎ Corresponding author. Tel.: +1 647 329 1911/647 680 2457. E-mail addresses: [email protected] (W.R.A.S. Rajapaksha), [email protected] (K.S. Cunningham), [email protected] (T.H. Rose). 1 Tel.: +1 416 314 4040.
interatrial septum. About a month later, he presented to a second hospital complaining of pain in the throat and chest, as well as dyspnea and palpitations. He was examined, diagnosed with AF, and discharged with changes to his medications. The next day, he presented to a third hospital after a fall at home, which resulted in a scalp laceration. He also complained of nausea, coughing up bloodtinged sputum, and right arm weakness. Uncontrolled AF as well as deviation of his eyes to the right was noted. A computed tomographic scan of the head revealed no intracranial pathology. Significant hematemesis commenced while in the emergency department, followed shortly by cardiac arrest and death. At postmortem examination, there were two lacerations on the occipital scalp, without underlying injury to the skull or brain. The pericardium appeared normal, but contained approximately 30 ml of serosanguineous fluid. The heart was enlarged with a weight of 500 g. The LA and both ventricles were dilated. The mediastinal soft tissue was congested and firm. The left atrial wall was adherent to the esophagus over an area of 2×2 cm, located inferior to the carina (Fig. 1). A fistula with a 9-mm diameter connected the midposterior wall of the LA, centered between the four PV ostia, to the midanterior wall of the esophagus (Fig. 2). Diffuse endocardial fibrosis was observed on the posterior wall of the LA, also centered between the PV ostia. Approximately 500 ml of blood was present in the stomach. Microscopically, the posterior wall of the LA showed coagulative necrosis of the myocardium and epicardial fat with organizing granulation tissue away from the fistulous tract (Fig. 3). There was mild subendocardial fibrosis adjacent to the involved myocardium. The anterior esophageal wall appeared unremarkable away from the fistula.
1054-8807/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.carpath.2014.02.004
Please cite this article as: Rajapaksha WRAS, et al, A fatal case of atrioesophageal fistula following radiofrequency ablation of left atrium and pulmonary veins for atrial fibrillation, Cardiovasc Pathol (2014), http://dx.doi.org/10.1016/j.carpath.2014.02.004
2
WRAS. Rajapaksha et al. / Cardiovascular Pathology xxx (2014) xxx–xxx
Fig. 1. Heart in relation to opened esophagus and stomach.
3. Discussion Cardiac dysrhythmias are a group of heterogeneous conditions due to abnormal electrical activity in the heart. AF, the most common, is associated with significant morbidity and mortality [1,2]. AF can be considered as chaotic, asynchronous electrical activity in atrial tissue and may be associated with contractile and structural remodeling. The two major complications of AF are hemodynamic compromise, the result of loss of the atrial contribution to ventricular filling, and formation of thrombi within the fibrillating atrium or atrial appendage [2,3]. Thrombi can embolize systemically to the brain and other major organs, causing downstream ischemia with consequent morbidity or possibly death [2]. AF requires an initiating trigger; most episodes are triggered within the PVs. Pharmacological therapy to restore and maintain sinus rhythm in patients with AF may be unsuccessful and dangerous. Elimination of trigger foci and modification of the myocardium through selective scarring are the bases of treatment by radiofrequency ablation techniques using ohmic heat [3]. Radiofrequency catheter ablation of the distal PVs and posterior LA is increasingly being used by interventional cardiac electrophysiologists to treat patients with AF [3–5]. Complications observed in patients who have undergone radiofrequency ablation [3] (Table 1) include endocardial charring, PV
Fig. 3. Photograph of whole-mount section of fistula in relation to esophagus and LA.
dissection, and atrial or PV perforation. Severe bradydysrhythmias can occur during the procedure due to stimulation of vagal nerve fibers within the walls of the PVs. Milder complications include small pleural or pericardial effusions. Small transient atrial septal defects and hemodynamically insignificant PV stenosis can also be seen. Fistulas may be congenital or acquired. Acquired fistulas usually result from injury or surgery; they can also result from infection or inflammation. Because of tissue damage to the LA and the nearby esophagus during radiofrequency ablation, a fistula may form to any nearby anatomical structure during the healing and remodeling process in up to 1% of cases [4]. Although intraatrial pressure is relatively low compared to ventricular pressure, a pressure gradient exists between the LA and the esophageal lumen. A significant quantity of blood can pass through a fistula into the esophagus and then into more distal portions of the gastrointestinal (GI) tract. This man’s neurologic findings shortly before death may be explained by air embolization through the fistula into the LA and ultimately into the cerebrovascular circulation. The history of hematemesis and the presence of blood in the stomach would indicate bleeding from the atrium, through the fistula, and into the GI tract. Therefore, the cause of death was given as upper GI hemorrhage due to a left atrioesophageal fistula, complicating radiofrequency ablation for the treatment of paroxysmal atrial fibrillation. In conclusion, left atrioesophageal fistula due to radiofrequency ablation for the treatment of AF is a rare, fatal condition. In the case of symptoms suggestive of this diagnosis, prompt treatment might be life saving.
Table 1 Serious adverse effects
Fig. 2. Closer view of fistula between LA and anterior wall of esophagus.
1
Chest discomfort
2 3 4 5 6 7 8 9 10 11 12 13 14
Pericardial effusion/tamponade Pneumothorax Hemothorax Permanent diaphragmatic paralysis Valve damage Sepsis, abscess, or endocarditis Atrial flutter/tachycardia Transient ischemic attack Stroke PV stenosis Arteriovenous fistula Atrioesophageal fistula Death
Please cite this article as: Rajapaksha WRAS, et al, A fatal case of atrioesophageal fistula following radiofrequency ablation of left atrium and pulmonary veins for atrial fibrillation, Cardiovasc Pathol (2014), http://dx.doi.org/10.1016/j.carpath.2014.02.004
WRAS. Rajapaksha et al. / Cardiovascular Pathology xxx (2014) xxx–xxx
3.1. Key points - Atrial fibrillation, the most common cardiac dysrhythmia, is associated with significant morbidity and mortality. - Radiofrequency catheter ablation of the distal PVs and posterior LA is increasingly being used. - Atrioesophageal fistula due to radio frequency ablation for AF is a rare, fatal complication.
4. Summary This case report illustrates the death of a 43-year-old man who developed a left atrioesophageal fistula following radiofre-
3
quency ablation of the LA and PVs for the treatment of atrial fibrillation. References [1] Keshishian J, Young J, Hill E, Saloum Y, Brady PG. Esophageal injury following radiofrequency ablation for atrial fibrillation: injury classification. Gastroenterol Hepatol 2012;8:411–4. [2] Gutierrez C, Blanchard DG. Atrial fibrillation: diagnosis and treatment. Am Fam Physician 2011;83(1):61–8. [3] Nielsen JC, et al. Radiofrequency ablation as initial therapy in paroxysmal atrial fibrillation. N Engl J Med 2012;367:1587–95. [4] Sause, et al. Limiting esophageal temperature in radiofrequency ablation of left atrialtachyarrhythmias results in low incidence of thermal esophageal lesions. BMC Cardiovasc Disord 2010;10:52. [5] Gokdeniz T, Aykan AC, Yildiz M, Celik S. Transvenous radiofrequency ablation therapy in the treatment of arrhythmias: a single center experience. Kosuyolu Kalp Derg 2013;16(1):36–41.
Please cite this article as: Rajapaksha WRAS, et al, A fatal case of atrioesophageal fistula following radiofrequency ablation of left atrium and pulmonary veins for atrial fibrillation, Cardiovasc Pathol (2014), http://dx.doi.org/10.1016/j.carpath.2014.02.004
