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Esophageal Duplication Cyst: A Rare Cause of Atrial Fibrillation in a Young Adult Patient JANET TSANG, M.D.,∗ FRANK W. BOWEN, M.D.,† MANISH DADHANIA, M.D.,∗ and ANDREA M. RUSSO, M.D.∗ From the ∗ Division of Cardiology, Department of Medicine; and †Division of Cardiothoracic Surgery, Department of Surgery, Cooper University Hospital, Camden, New Jersey, USA

cardiac anatomy, atrial fibrillation, esophageal cyst, surgery, congenital malfunction A 27-year-old male was referred to our hospital for radiofrequency catheter ablation of symptomatic medicationresistant atrial fibrillation (AF). Chest x-ray and echocardiogram were unremarkable. He underwent a preprocedure cardiac MRI to evaluate pulmonary vein anatomy. Imaging revealed a circumscribed mediastinal mass, 3.9 cm × 3.0 cm × 5.7 cm, located immediately posterior to the right inferior pulmonary vein, and abutting the pericardium, esophagus, and thoracic spine (Fig. 1). Given concerns for possible rupture, as well as the suspicion that this structure was the trigger for his AF, the ablation was cancelled and the patient subsequently underwent robotic-assisted surgical resection of the J Cardiovasc Electrophysiol, Vol. 25, pp. 1259-1260, November 2014. Dr. Russo reports participation on research grants supported by Medtronic and Boston Scientific; she received honoraria relevant to this topic from Medtronic, Boston Scientific and St. Jude Medical. Dr. Dadhania participated in the CABANA trial, sponsored in part by St. Jude Medical and Biosense Webster, as a co-investigator. Other authors: No disclosures. Address for correspondence: Janet Tsang, M.D., Cooper University Hospital, Division of Cardiology, Dorrance Building, 4th floor, 1 Cooper Plaza, Camden, NJ 08103. Fax: 856-968-8282; E-mail: [email protected] doi: 10.1111/jce.12471

mass (Fig. 2). Pathology revealed an esophageal duplication cyst. He was maintained on propafenone for 5 weeks postoperatively and remained asymptomatic after discontinuation of antiarrhythmic therapy. Mobile telemetry performed from the second through the sixth postoperative weeks showed no evidence of recurrent AF. A 24-hour Holter monitor done 10 months after surgery demonstrated no arrhythmias. One year after surgical intervention, he remains symptom-free and without any known recurrence of AF. While supraventricular tachycardia as a treatable cause of paroxysmal atrial fibrillation in younger patients is well documented, mechanical etiologies, including mediastinal masses that cause extrinsic compression of native cardiac anatomy, are less commonly described. The purported mechanism is direct compression or mechanical irritation of the left atrium and/or pulmonary veins. Stretching and distortion of the atrial myocardial fibers and the pulmonary veins are thought to lead to abnormal myocytes firing, setting up ectopic foci for atrial fibrillation. Surgical resection of these lesions can result in long-term resolution of atrial fibrillation and maintenance of sinus rhythm. Congenital mediastinal cysts are a rare but important etiology for the differential diagnosis of treatmentresistant atrial fibrillation in younger patients with otherwise structurally normal hearts.

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Vol. 25, No. 11, November 2014

Figure 1. A TrueFISP sequence of the preprocedure cardiac MRI (A) demonstrates the proximity of the esophageal duplication cyst to the left atrium and pulmonary veins. A dark blood sequence (B) confirms that the cyst is not an anomalous vascular structure.

Figure 2. An intraoperative view shows the spatial relationship of the esophageal duplication cyst to the pericardial sac. For a high quality, full color version of this figure, please see Journal of Cardiovascular Electrophysiology’s website: www.wileyonlinelibrary.com/journal/jce

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Esophageal duplication cyst: a rare cause of atrial fibrillation in a young adult patient.

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