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Atrio-esophageal fistula (AEF) development after catheter ablation for atrial fibrillation is a major complication which is hard to recognize and presents with fever and neurological symptoms. When clinical symptoms raise concerns about AEF, demonstration of the fistula by imaging methods followed with surgical therapy is recommended. However, it is challenging to choose treatment strategy when conventional imaging methods fail to detect AEF. Here we present a case of AEF after catheter ablation for atrial fibrillation that was successfuly treated surgically and the treatment strategy was chosen based on highly clinical suspicion although the fistula could not be visualized.
A 57 year-old male patient with no remarkable history other than hypertension presented to our outpatient clinic for palpitation symptoms despite medical therapy. The patient had atrial fibrillation in his admission electrocardiogram with a heart rate of 95 beats per minute. Left atrium and pulmonary veins anatomy were reconstructed by CARTO electroanatomic mapping method after transseptal puncture. Ostia of pulmonary veins were circumferentially ablated point-by-point via Lasso catheter (Lasso; Biosense Webster, Diamond Bar, CA,USA). The patient presented with fever 20 days after the procedure and was followed by the infectious disease specialist with the preliminary diagnosis of infective endocarditis. Blood culture tests were positive for Enterococcus species and appropriate antibiotic therapy was initiated. Initial computed tomography (BT) in order to rule out AEF did not show any signs of AEF so antibiotic regimen was continued. Five days after admission the patient suffered significant impairment in reading and writing skills and diffuse magnetic resonance imaging (MRI) revealed ischemic area in left temporal cortical area with simultaneous hemorrhagic foci. The condition of the patient was evaluated by the Heart Team and urgent surgery was scheduled despite failure to show AEF. Left atriotomy was performed following sternotomy. Ostium of the fistula in 2.5 mm size was detected adjacent to left inferior pulmonary vein in the left atrium. The fistula was sutured with pericardial support. Left atrium was closed and the heart was examined posteriorly, purse-string suture with autologous pericardial support was performed in the area adjacent to left inferior pulmonary vein through the estimated fistula line. The patient continued to receive antibiotic therapy for 4 weeks after the operation and esophagoscopy revealed no signs of fistula. Control diffuse MRI showed no remarkable lesion but stable hemorrhagic foci and the follow-up is uneventful under warfarin therapy.