Alternative Operative Strategy in the Management of an Atrio-Esophageal Fistula

An atrio-esophageal fistula is a rare sequela of ablation. Standard approaches are associated with a high mortality. Atrial ablation resulting in an atrio-esophageal fistula is associated with exceedingly high mortality. The treatment of an atrio-esophageal fistula is time-sensitive since complications such as sepsis and air emboli can arise from a delay in diagnosis, potentially worsening outcomes. We report an 82-year-old female patient presenting with right-sided hemi-paralysis, shortness of breath, productive cough, and intermittent fevers one month after an atrial radiofrequency ablation procedure. Our technique of fistula repair with division and ligation of the esophagus in this unstable patient, avoiding cardiopulmonary bypass, is discussed. Cardiopulmonary bypass requires systemic anticoagulation, and may not be suitable for a patient who presents with neurologic symptoms and evidence of embolic stroke on imaging due to the risk of hemorrhagic conversion. Her 22-day post-surgical management and course of recovery, which include a cervical esophagostomy, vocal cord paralysis, and right lower lobe pneumonia are also discussed. This off-bypass technique may be useful in some patients.