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2024 AF Symposium
Challenging Cases in AF Management: Fixing an Atrial Esophageal Fistula Without Surgery
Always one of the most interesting presentations at the AF Symposium is the section “Challenging Cases in AF Management and Stroke Prevention.” Some of the world’s leading EPs talk about the most difficult cases they had to struggle with.
The panelists this year were:
Moderator: Dr. David Keane of St. Vincent’s Hospital, Dublin, Ireland
• Dr. John Day of the Intermountain Heart Institute, Murray, UT
• Dr. Isabel Deisenhofer of St. Jan University, Brugge-Oostende, Belgium
• Dr. Gerhard Hindricks of the University of Leipzig, Leipzig, Germany
• Dr. Young-Hoon Kim of the Korea University Medical Center, Seoul, Korea
• Dr. Laurent Macle of the Montreal Heart Institute, Montreal, Canada
Background: How Does Atrial Esophageal Fistula Happen? The esophagus often lies just behind the posterior wall of the left atrium. During an ablation, heat from the RF (radio frequency) catheter applied to the back of the heart can damage the esophagus. (This can also happen during a Cryo ablation.)
If RF heat damages the esophagus, ulcer-like lesions form in the esophagus. In the 2-3 weeks following the ablation (post-ablation), gastric acids (reflux) can eat away at these lesions creating a fistula (hole) leading from the esophagus into the heart. Without major intervention, stomach contents can pass from the esophagus into the heart, leading to bloodstream infection (sepsis) and death. Though this happens very rarely (one in 1000+ cases), it can kill or severely disable. (With the new Pulse Field Ablation technology, the esophagus is protected from damage.)
Dr. Young-Hoon Kim
The Case of Dr. Young-Hoon Kim
Dr. Young-Hoon Kim, Korea University Anam Hospital, Seoul, South Korea, described the case of a 58-year-old female who had been on amiodarone and was very thin. She developed a high fever and myalgia (muscle aches and pain) as well as hypertension that resulted in a state of shock.
Dr. Kim knew these were possible symptoms of an Atrial Esophageal Fistula. (The panelists concurred.) Something had to be done within a few hours or she would die.
No Surgeon Available: How to Close Off the Esophagus?
At that time no surgeon or surgical facility was available to Dr. Kim.
What did Dr. Kim do? He reversed the blood flow from the aorta and minimized ejection pumping. Then he patched the hole in the atrium with a suture.
This worked! The woman survived thanks to Dr. Kim’s quick thinking and action.
