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E1246. Atrial Esophageal Fistula: A Case Report with CT Imaging, Intraoperative Photographs, and Brief Review
Authors
  1. David Kupshik; Memorial University Medical Center
  2. Chris Burns; Memorial University Medical Center
  3. Brittany Matthews; Memorial University Medical Center
  4. Matthew Dixon; Memorial University Medical Center
  5. Mike Flynn; Memorial University Medical Center
Background
Atrial to esophageal fistula’s (AEF’s) can be defined as an abnormal communication between the atrium and the esophagus. This often occurs as a result of a trauma, although idiopathic fistulas have been described in the literature (Aghasadeghi). AEF is a rare but serious complication of catheter ablation for atrial fibrillation (AF) with an incidence of 0.01-0.02% (Brume) and mortality rates reported as high as 67-100% (Brownwell). Previous analysis has shown a 15% rise in the rates of AF ablations resulting in an increase ablations from 0.06% of AF patients receiving ablation to 0.79% over 15 years (1990–2005 period), which follows a rise in the prevalence of AF itself from 270,000 to over 2.2 million people affected (Kneeland). AEF’s are more common in males (Chavez), though this could be due to the fact that men select to undergo invasive treatment with radiofrequency ablation (RFA) (Finsterer). AEF occurs most commonly after radio frequency ablation (Brownell), but has been reported with all approaches to AF ablation (Nair).

Educational Goals / Teaching Points
We present a case from our facility: A 53 y.o female with a PMH of atrial ablation eventually diagnosed with atrial-esophageal fistula; a detailed patient course to be described on the poster. In the complete presentation, we want to talk about Risk factors for AEF. The signs and symptoms of AEF . Diagnostic testing Treatment options and prognosis.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
The anatomic issue is a fistula between the left atrium and the esophagus. Unfortunately, the understanding of the pathogenesis of AEF is incomplete. There are numerous theories as to the pathophysiology and formation of AEFs, as well as intraoperative, in the setting of ablation, techniques and tools that may increase or decrease the risk of AEF. CT Chest w/o contrast 2.9 x 2.2 cm gas/fluid collection within the mediastinum in the transverse pericardial recess with gas extending towards the esophagus. We also have intraoperative photos from our case.

Conclusion
AEF is a rare but serious complication of all forms of ablation for atrial fibrillation. While it is an exceedingly rare entity, it will only become more prevalent as the prevalence of atrial fibrillation, and thus number of ablation procedures, increases. The clinical picture of AEF is highly variable and often very non specific. If left untreated, AEF can have very serious consequences such as stroke and death. Prompt diagnosis is crucial and any instrumentation down the esophagus is contraindicated due to the potential of precipitating an embolism. Treatment is either surgical or conservative, though surgery is considered the standard of care. Here, we present a case of Left Atrial AEF in a patient with a history of recent ablation who presented with chest pain and STEMI. This case and review highlights the importance of keeping atrial esophageal fistula in mind in patients with a history of ablation and constitutional, neurologic, or coronary symptoms.