Abstract
A 58-year-old man presented with fever and chest pain 11 days after atrial fibrillation catheter ablation. The diagnosis of pericardio-oesophageal fistula was made. Aggressive surgical management was decided. The patient was managed using extracorporeal life support, aortic valve replacement and a pulmonary patch, as well as an oesophageal stent. The patient was discharged from hospital approximately 2 months later. The use of a pulmonary patch is a rare but a highly effective technique that can be used in this indication.
INTRODUCTION
Pericardio-oesophageal fistula (POF) is a rare life-threatening complication of atrial fibrillation (AF) catheter ablation. Its management is not clearly established. We present a case of a 58-year-old man who suffered a POF following AF catheter ablation and who was surgically managed by oesophageal stenting as well as an oesophageal closure using a pulmonary patch under cardiopulmonary bypass.
CASE REPORT
A 58-year-old man suffering from AF and aortic valve regurgitation underwent percutaneous catheter AF ablation. Immediate post-procedural echocardiography confirmed sinus rhythm associated with a 2-mm pericardial effusion. The patient was discharged home on the 2nd post-procedural day.
Eleven days after the procedure, the patient was admitted to the nearest emergency department because of chest pain, dysphagia, fever and hypotension. A computed tomography scan revealed a pneumopericardium and a significant pericardial effusion. Analysis of the oesophagus and posterior mediastinum was described as normal. The patient was subsequently transferred to the cardiac intensive care unit of our University Hospital. An ensuing computed tomography scan with a water-soluble contrast material-enhanced oesophagram was performed and confirmed a POF associated with acute mediastinitis (Fig. 1). The same day, a fully covered oesophageal metal stent was inserted. The patient was thereafter transferred to the operating room for definitive surgical treatment. Following complete sternotomy and evacuation of turbid septic fluid as well as septic solid material, cardiopulmonary bypass was initiated. The right atrium had to be opened to perform a retrograde cardioplegia. A large patent foramen oval was discovered and was sutured after having verified that the posterior aspect of the left atrium was not perforated. The heart was mobilized to gain access to the posterior pericardium; a large defect was noted, and the previously deployed oesophageal stent was largely visible.
Computed tomography scan obtained on admission. The arrow indicates the contrast material leaking from the oesophagus into the pericardium. The asterisk indicates the pericardial effusion with air filling the upper aspect of the effusion.
A pulmonary patch from the right lower lobe was harvested using an endo-stapler and then stitched to the oesophageal fistula using absorbable polydioxanone sutures.
Weaning from the cardiopulmonary bypass failed due to significant underestimated aortic valve regurgitation. Central extracorporeal life support was hence required.
On postoperative Day 1, the decision was made to replace the aortic valve as the patient exhibited reduced local sepsis. On postoperative Day 10, upon improvement of the patient’s general condition, extracorporeal life support was removed, and a feeding jejunostomy was performed. Thirty days after his admission, the patient was discharged from the intensive care unit; 26 days later, he was admitted to a rehabilitation centre.
The oesophageal stent was removed 7 weeks after its implantation, no residual leakage was detected and a control computed tomography scan confirmed perfect healing (Fig. 2).
Postoperative computed tomography scan. The solid arrow indicates the staple line of the pulmonary patch sewn to the oesophagus. The dotted arrow points to the oesophageal stent still in place.
COMMENT
POF is now a well-identified complication of AF ablation therapies. Surveys on catheter ablation for AF have reported a 0.015–0.04% incidence of confirmed POF accounting for 16% of morbidity cases [1].
Management of a POF remains unclear; oesophageal stenting alone has been successfully reported [2], although definitive surgical treatment appeared to enhance survival [3] in larger case series. The decision was made herein to harvest a pulmonary patch. The procedure involved performing a wedge resection of the basal segment in the right lower lobe pediculated on the remaining lobe. Such a patch has already been reported in the repair of tracheobronchial necrosis secondary to caustic ingestion [4], although, to the best of our knowledge, this is the first report of such use in the treatment of oesophageal fistula. Another option could have been a greater omentum flap; however, we believed it was likely better to preserve this peritoneal fold in case of large postoperative sternal osteitis. An intercostal muscle flap could have been used but was not easily available via a sternotomy.
In conclusion, POF is a life-threatening condition that requires prompt surgical treatment; we believe an aggressive management is more likely to decrease mortality. The use of a pulmonary patch is a feasible option in a septic environment. It is also easily available, especially when the patient is on cardiopulmonary bypass. Its combination with an oesophageal stent appears to increase the likelihood of oesophageal healing as well as adequate nutritional and antimicrobial support.
Conflict of interest: none declared.
