Author + information
- Received March 13, 2017
- Revision received March 27, 2017
- Accepted March 30, 2017
- Published online December 4, 2017.
- Jacob S. Koruth, MD∗ (, )
- Edward W. Chu, MD,
- Rahul Bhardwaj, MD,
- Srinivas Dukkipati, MD and
- Vivek Y. Reddy, MD
- ↵∗Address for correspondence:
Dr. Jacob S. Koruth, Helmsley Electrophysiology Center, Mount Sinai Hospital and School of Medicine, One Gustave L. Levy Place, PO Box 1030, New York, New York 10029.
We describe a pericardioesophageal defect resulting from thermal injury during epicardial left ventricular tachycardia ablation in a 69-year-old man who failed 2 endoepicardial ablation attempts. Ventricular tachycardia was localized to the scar (Figure 1A). Unipolar radiofrequency ablation (Smart Touch, Thermocool catheter [Biosense Webster, Diamond Bar, California]) from the endocardium, epicardium, and coronary sinus failed and bipolar radiofrequency (epi-endocardium) was needed to render the ventricular tachycardia noninducible. The patient was discharged home on rivaroxaban but presented 3 days later with cardiac tamponade requiring drainage. The patient was initiated on oral colchicine and anticoagulation was discontinued. One month later, the patient presented with hematemesis and a mass located at 30 cm from the incisors was seen on endoscopy (Figure 1B). Before further investigation or treatment, the patient developed massive hematemesis and expired. At postmortem, a gastric ulcer (Figure 1C) with evidence of recent bleeding was seen and determined to be the cause of death (unrelated to ablation). Examination of the esophagus revealed a probe-patent defect (Figure 1D) that communicated with the posterior pericardium but not with any cardiac structures.
A previous report described a mediastinal-esophageal fistula after an epicardial procedure (1). These 2 reports taken together provide a rationale for operators to be wary of esophageal injury when ablating basally in the epicardium (Figure 2). It is important to note that the coronary sinus radiofrequency applications were few and only of short duration and that the bipolar lesions are unlikely to have played any additional role beyond that of an additive epicardial heat source.
Dr. Koruth is a consultant to Biosense Webster. Dr. Dukkipati has received a research grant for bipolar catheter ablation from Biosense Webster. Dr. Reddy is a consultant for Biosense Webster. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
All authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Received March 13, 2017.
- Revision received March 27, 2017.
- Accepted March 30, 2017.
- 2017 American College of Cardiology Foundation