Am Fam Physician. 2023;108(6):online
Author disclosure: No relevant financial relationships.
To the Editor:
A 48-year-old woman had a planned catheter ablation for paroxysmal atrial fibrillation. Two days after her ablation, the patient presented to the emergency department with chest pain. The initial evaluation, including chest radiography, found no acute pathology. Four days later, the patient followed up at her family medicine clinic, reporting unrelenting nausea, vomiting, and the sensation of pills getting stuck in her throat. A physical examination and blood test results were unremarkable. The patient returned to the emergency department five days later with ongoing symptoms. Pulmonary embolism was excluded with computed tomography angiography of the chest, and the patient was discharged with a follow-up appointment scheduled with her cardiologist. During her cardiology visit, transthoracic echocardiography did not find any abnormalities.
One week later, the patient presented a third time to the emergency department with hypoxic respiratory failure and was admitted to the intensive care unit with sepsis, Streptococcus pneumoniae bacteremia, and Candida fungemia. The patient was intubated after her respiratory status deteriorated on continuous bilevel positive airway pressure. Transesophageal echocardiography found a large mobile density in the left atrium. The inpatient care team decided to transfer the patient to a tertiary care center; however, she was pronounced brain dead on arrival, and the family consented to withdraw her care.
A postmortem examination determined that the patient had an atrial-esophageal fistula, a rare but known complication of catheter ablation. An atrial-esophageal fistula is estimated to occur in less than 0.1% to 0.25% of cases and can develop up to six weeks after the procedure.1 Signs and symptoms are relatively nonspecific, often leading to a delay in the diagnosis. Mortality from this complication is 100% if left untreated. This case highlights a rare and catastrophic complication from a routine procedure for restoring sinus rhythm in a patient with atrial fibrillation.
