Author + information
- Received November 30, 2015
- Accepted December 10, 2015
- Published online June 1, 2016.
- Fu Siong Ng, MBBS, PhDa,b,∗ (, )
- Ben Ariff, MBBS, PhDa,
- Prakash P. Punjabi, MBBSa,b,
- George B. Hanna, MBBCh, PhDa,b,
- John Cousins, MBBSa,
- Nicholas S. Peters, MBBS, MDa,b,
- Prapa Kanagaratnam, MBBChir, PhDa,b and
- Phang Boon Lim, MBBChir, PhDa,b
- aImperial College Healthcare NHS Trust, London, United Kingdom
- bImperial College London, London, United Kingdom
- ↵∗Reprint requests and correspondence:
Dr. Fu Siong Ng, 4th Floor, Imperial Centre for Translational and Experimental Medicine, Imperial College London, Hammersmith Campus, Du Cane Road, London W12 0NN, United Kingdom.
A 64-year old woman underwent radiofrequency atrial fibrillation ablation by wide area circumferential ablation. Three weeks after the procedure, she was readmitted with possible sepsis, although the focus of infection was unclear. A nasogastric tube was passed, and chest radiography performed to assess its position, which revealed a large pneumopericardium (Figure 1A) not present on admission (Figure 1B). A thoracic computed tomography scan with oral contrast revealed large volume pneumopericardium and a large pericardial effusion, with thin septae noted (Figure 2). There were appearances suggestive of gas locules and extraluminal contrast anterior to the esophagus, which pointed toward a possible esophageal leak. The patient underwent emergency surgery within 24 h. A significant amount of pus was found within the pericardial space, which grew Candida on microbiological analysis, although no fistula between the pericardium and the esophagus, nor clear evidence of esophageal perforation, was found. The pericardial space was washed out, and a pericardiectomy was performed; no esophageal repair was needed. The patient was treated with antifungal medications, with a subsequent computed tomography scan confirming resolution of the pyopneumopericardium (Figure 3).
Although no clear perforation or fistula was demonstrated during surgery, a pericardioesophageal fistula that had sealed off by the time of surgery remained the most likely diagnosis. Atrio-esophageal fistula (AEF) formation is a rare but recognized serious complication of atrial fibrillation ablation associated with a mortality rate >70% (1–3); pericardioesophageal fistula formation is a variant of this complication. AEF occurs in <0.1% of atrial fibrillation ablation cases, often presenting 1 to 4 weeks after ablation, with fever and features of sepsis, neurological symptoms from air emboli, gastrointestinal symptoms, or with striking radiological findings of air in the pericardium or mediastinum, as illustrated in this case (1–4). The surgical procedure was not technically demanding, and urgent surgical intervention should be considered in patients presenting with symptoms of AEF.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received November 30, 2015.
- Accepted December 10, 2015.
- American College of Cardiology Foundation
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