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Atrioesophageal fistula following pulmonary vein isolation via radiofrequency ablation presenting as infective endocarditis
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  • Andrea Rueda Liñares,
  • Alexander Marschall,
  • Hugo Del Castillo Carnevali,
  • Diego Rodrígez Torres,
  • David Martí Sánchez,
  • Cristina Fraile Sanz,
  • Salvador Álvarez Antón
Andrea Rueda Liñares
Cardiovascular Department, Hospital Universitario Gómez Ulla, Glorieta del Ejército s/n, 28047, Madrid, Spain.

Corresponding Author:[email protected]

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Alexander Marschall
Hospital Central de la Defensa Gomez Ulla
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Hugo Del Castillo Carnevali
Hospital Central de la Defensa Gomez Ulla
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Diego Rodrígez Torres
Hospital Central de la Defensa Gomez Ulla
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David Martí Sánchez
Hospital General de la Defensa
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Cristina Fraile Sanz
Hospital Central de la Defensa Gomez Ulla
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Salvador Álvarez Antón
Hospital Central de la Defensa Gomez Ulla
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Abstract

Catheter ablation(CA) is an increasingly used therapeutic tool for the treatment of atrial fibrillation (AF). Atrioesophageal fistula (AEF) is one of the most dreaded complications of CA and its incidence ranges from <0.1% to 0.25% .Despite its rarity, AEF accounts for a high proportion among fatal complications of AF ablation. We present a rare case of AEF after cryo-ablation presenting as infective endocarditis. A 73-year-old male with history of pulmonary vein isolation using radiofrequency ablation 4 weeks prior to admission, presented with fever and abdominal pain.Shortly after admission the patient presented with severely depressed level of consciousness and seizure. Cerebral computer tomography (CT) was normal, whereas abdominal CT showed a small splenic infarction.Subsequent magnetic resonance imaging (MRI) of the brain demonstrated extensive cortical and subcortical ischemic lesions via diffusion weighed MRI (Panel A). Transoesophageal echocardiography (TOE) revealed two oscillating masses, compatible with infectious vegetations, at the insertion of the superior pulmonary vein and at the superior left atrial wall (Panel B, arrows, Supplementary Data online, Videos 1-3).Mitral, aortic, tricuspid and pulmonary valves did not present vegetations.The left atrial appendage was free of thrombus. Contrast enhanced chest CT showed free air between the left oesophageal wall and the posterior left atrial wall, as well as inside the left atrium (Panel C, arrow), thus confirming the diagnosis of iotrogenic atrioesophageal fistula. At the time of diagnosis the patient presented clinical signs of decerebration. Given the severe neurological deterioration, surgical intervention was not considered and the patient deceased shortly after extubation.