Objective:

To highlight a rare cerebrovascular complication of left atrial ablation

Background:

Percutaneous and surgical ablation are increasingly being used in management of atrial fibrillation (AF). Atrio-esophageal fistula (AEF) is the most serious complication of AF ablation with an estimated incidence of 0.03%-0.08%. AEF usually develops 1-6 weeks after AF ablation. Under-reporting and misdiagnosis are common. Cerebral air embolism is a rare and near-fatal complication of AEF.

Design/Methods:

Literature review

Results:

66-year-old man with history of atrial fibrillation, heart failure with reduced ejection fraction (HFrEF), hypertension, and recent Pulmonary vein isolation (PVI) with Left atrial modification for AF presented to an outside hospital with confusion, slurred speech and left-sided weakness.

Initial CTH showed trace pneumocephalus along the left anterior frontal and right parietal areas, within the subarachnoid space. CTA chest revealed small punctate air behind the left atrium with bunching concerning for an atrio-esophageal fistula. He underwent emergent surgical repair of the fistula and was admitted to the cardiac intensive care unit. MRI showed scattered infarcts in bilateral hemispheres. Despite initial improvement, his condition deteriorated due to recurrent embolic infarcts, and progressive neurological decline. Subsequently, the patient suffered cardiac arrest with pulseless electrical activity (PEA), but ROSC was achieved. Coronary angiography revealed embolic occlusion of the distal right posterior descending artery and posterolateral branch. He then developed basilar occlusion with unsuccessful thrombectomy and eventually succumbed during the hospitalization

Conclusions:

AEF is a serious complication of AF associated with high morbidity and mortality. Clinicians should have high suspicion for development of AEF in patients presenting with acute neurological symptoms soon after AF ablation. Additionally, it is important to recognize that multiple stroke etiologies may co-exist, as in this case where both air embolism and underlying atrial fibrillation likely contributed to recurrent infarcts. Early recognition and intervention can minimize disability and improve survival rates.