562102 research-article2014
PRF0010.1177/0267659114562102PerfusionKoa-Wing et al.
Original paper
Haemorrhagic cerebral air embolism from an atrio-oesophageal fistula following atrial fibrillation ablation
Perfusion 1–3 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0267659114562102 prf.sagepub.com
M Koa-Wing, S Jamil-Copley, B Ariff, P Kojodjojo, PB Lim, Z Whinnett, S Rajakulendran, P Malhotra, D Lefroy, NS Peters, DW Davies and P Kanagaratnam
Abstract We report the case of a man found unconscious three weeks following atrial fibrillation (AF) ablation. Cranial and thoracic imaging demonstrated multiple areas of pneumo-embolic infarction secondary to an atrio-oesophageal fistula (AEF). AEF is a recognised, but rare, complication of AF ablation.1–8 Early recognition is critical as the mortality is 100% without surgical intervention. We consider the postulated mechanisms of AEF formation, the spectrum of clinical presentation, investigations and treatment. Keywords atrio-oesophageal fistula; atrial fibrillation ablation
Case History A 45-year-old man was found collapsed and unresponsive at home with evidence of coffee-ground vomiting. On arrival to casualty, he was pyrexial with a Glasgow Coma Scale score of 8. He deteriorated rapidly, necessitating intubation, ventilation and transfer to intensive care. Collateral history included paroxysmal AF, having undergone an apparently uncomplicated AF ablation procedure three weeks previously. Notably, he had consulted his General Practitioner (GP) two weeks postprocedure complaining of abdominal pain and had been referred for endoscopy. Medical history included rheumatoid arthritis. Drugs included: prednisolone, omeprazole, flecainide, bisoprolol and warfarin. Admission computed tomography (CT) head revealed a small frontal infarct, insufficient to explain the patient’s obtunded state. Blood cultures grew Streptococcus viridans for which antibiotics were commenced. An oesophagogastroduodenoscopy (OGD) was performed which showed gastric erythema only. Heparin was commenced on suspicion of cardioembolic cerebral infarction in the context of the recent ablation and known AF. A transthoracic echocardiogram excluded vegetations, but suggested an extracardiac lesion related to the left atrium (LA). To further evaluate, a thoracic CT demonstrated air in
the LA and mediastinum (Figure 1A) along with the presence of two tracts between the LA and the oesophagus, strongly suggestive of an atrio-oesophageal fistula (AEF). A repeat CT head revealed locules of air associated with extensive areas of infarction and haemorrhage transformation in the cerebellum and both cerebral hemispheres (Figure 1B, 1C). The patient continued to deteriorate neurologically before surgery could be undertaken and died due to septicaemia and severe progressive neurological damage. A post mortem was not undertaken on account of family wishes.
Imperial College Healthcare NHS Trust, St Mary’s Hospital, London, UK Corresponding author: Dr. Prapa Kanagaratnam Department of Cardiology Mary Stanford Wing St. Mary’s Hospital Imperial College Healthcare NHS Trust London W2 1NY UK. Email: [email protected]
Downloaded from prf.sagepub.com at CAMBRIDGE UNIV LIBRARY on January 5, 2015
2
Perfusion
Figure 1. A: CT thorax in cross-section demonstrating air in the left atrium (arrowed). B: Repeat CT head of the patient undertaken following further neurological deterioration demonstrating locules of air (arrowed). C: CT head also showing widespread areas of infarction with haemorrhage. CT: computed tomography.
Discussion AEF is an abnormal communication between the left atrial posterior wall and the oesophagus. It is a recognised, but rare, complication of AF ablation, with a reported worldwide incidence of
PRF0010.1177/0267659114562102PerfusionKoa-Wing et al.
Original paper
Haemorrhagic cerebral air embolism from an atrio-oesophageal fistula following atrial fibrillation ablation
Perfusion 1–3 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0267659114562102 prf.sagepub.com
M Koa-Wing, S Jamil-Copley, B Ariff, P Kojodjojo, PB Lim, Z Whinnett, S Rajakulendran, P Malhotra, D Lefroy, NS Peters, DW Davies and P Kanagaratnam
Abstract We report the case of a man found unconscious three weeks following atrial fibrillation (AF) ablation. Cranial and thoracic imaging demonstrated multiple areas of pneumo-embolic infarction secondary to an atrio-oesophageal fistula (AEF). AEF is a recognised, but rare, complication of AF ablation.1–8 Early recognition is critical as the mortality is 100% without surgical intervention. We consider the postulated mechanisms of AEF formation, the spectrum of clinical presentation, investigations and treatment. Keywords atrio-oesophageal fistula; atrial fibrillation ablation
Case History A 45-year-old man was found collapsed and unresponsive at home with evidence of coffee-ground vomiting. On arrival to casualty, he was pyrexial with a Glasgow Coma Scale score of 8. He deteriorated rapidly, necessitating intubation, ventilation and transfer to intensive care. Collateral history included paroxysmal AF, having undergone an apparently uncomplicated AF ablation procedure three weeks previously. Notably, he had consulted his General Practitioner (GP) two weeks postprocedure complaining of abdominal pain and had been referred for endoscopy. Medical history included rheumatoid arthritis. Drugs included: prednisolone, omeprazole, flecainide, bisoprolol and warfarin. Admission computed tomography (CT) head revealed a small frontal infarct, insufficient to explain the patient’s obtunded state. Blood cultures grew Streptococcus viridans for which antibiotics were commenced. An oesophagogastroduodenoscopy (OGD) was performed which showed gastric erythema only. Heparin was commenced on suspicion of cardioembolic cerebral infarction in the context of the recent ablation and known AF. A transthoracic echocardiogram excluded vegetations, but suggested an extracardiac lesion related to the left atrium (LA). To further evaluate, a thoracic CT demonstrated air in
the LA and mediastinum (Figure 1A) along with the presence of two tracts between the LA and the oesophagus, strongly suggestive of an atrio-oesophageal fistula (AEF). A repeat CT head revealed locules of air associated with extensive areas of infarction and haemorrhage transformation in the cerebellum and both cerebral hemispheres (Figure 1B, 1C). The patient continued to deteriorate neurologically before surgery could be undertaken and died due to septicaemia and severe progressive neurological damage. A post mortem was not undertaken on account of family wishes.
Imperial College Healthcare NHS Trust, St Mary’s Hospital, London, UK Corresponding author: Dr. Prapa Kanagaratnam Department of Cardiology Mary Stanford Wing St. Mary’s Hospital Imperial College Healthcare NHS Trust London W2 1NY UK. Email: [email protected]
Downloaded from prf.sagepub.com at CAMBRIDGE UNIV LIBRARY on January 5, 2015
2
Perfusion
Figure 1. A: CT thorax in cross-section demonstrating air in the left atrium (arrowed). B: Repeat CT head of the patient undertaken following further neurological deterioration demonstrating locules of air (arrowed). C: CT head also showing widespread areas of infarction with haemorrhage. CT: computed tomography.
Discussion AEF is an abnormal communication between the left atrial posterior wall and the oesophagus. It is a recognised, but rare, complication of AF ablation, with a reported worldwide incidence of
