Successful Anesthetic Management for Surgical Repair of Atrio-Esophageal Fistula Following Radiofrequency Ablation for Atrial Fibrillation

doi:10.4236/ojanes.2013.38075

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Open Journal of Anesthesiology, 2013, 3, 353-355

http://dx.doi.org/10.4236/ojanes.2013.38075 Published Online October 2013 (http://www.scirp.org/journal/ojanes) 353

Successful Anesthetic Management for Surgical Repair of

Atrio-Esophageal Fistula Following Radiofrequency

Ablation for Atrial Fibrillation

Atsushi Yasuda, Paul H. Alfille, Lisa T. Wollman-Kliman

Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, USA.

Email: [email protected]

Received July 17th, 2013; revised August 15th, 2013; accepted August 26th, 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Introduction: Atrio-esophageal fistula is a rar e but often fatal complication of radiofre quency ablation for atrial fibril-

lation. Here we report a successful case in anesthetic management of surgical repair of atrio-esophageal fistula. Case

Report: The patient was a 56-year-old man status post radiofrequency ablation for atrial fibrillation one month before

presenting with fever and symptoms and signs of cerebral emboli. He was diagnosed as having atrio-esophageal fistula,

which required emergent surgical repair. In the operating room, rapid sequence induction was performed with avoid-

ance of positive pressure ventilation before securing airway. Double lumen tube was used for lung isolation for left tho-

racotomy. Upon exploration, a small fistula was identified. Both atrial and esophageal defects were ligated and an in-

tercostal muscle flap was placed. The patient’s heart rhythm was atrial flutter/atrial fibrillation with marginal hemody-

namics during the procedure, but cardioversion was delayed until the fistula was repaired and no remaining air, blood

clot or gastric content in the heart was confirmed by epicardial ultrasound. The patient tolerated the surgery and was

transferred to ICU, intubated and ventilated. He recovered from surgery and was transferred to a reha bilitation hospital

with residual expressive aphasia. Conclusion: We had a successful case in anesthetic management for surgical repair of

atrio-esophageal fistula by preventing massive bleeding as well as multiple air embolization through the fistula.

Keywords: Atrial Fibrillation; Radiofrequency Ablation; Complication; Atrio-Esophageal Fistula; Anesthetic

Management

1. Introduction

Atrial fibrillation is the most common clinically relevant

heart rhythm disorder. Radiofrequency ablation is widely

performed as a treatment for recurrent, drug-resistant

atrial fibrillation. Atrio-esophageal fistula is a rare but

often fatal complication of radiofrequency ablation for

atrial fibrillation. There are no reports on anesthetic

management for surgical repair of atrio-esophageal fis-

tula. Here we report a successful case in anesthetic man-

agement of 56-year-old man who underwent emergent

surgical repair of atrio-esophageal fistula.

2. Case Report

The patient was a 56-year-old man (85 kgw) with history

of chronic deep venous thromboses (DVT) and factor V

Leiden deficiency on warfarin therapy and recurrent par-

oxysmal atrial fibrillation. He underwent successful ra-

diofrequency ablation/pulmonary vein isolation for atrial

fibrillation at an outside institution. The initial post-pro-

cedure course was uneventful and he maintained normal

sinus rhythm. One month later he developed symptoms

of progressive malaise, high fevers, and intermittent

speech difficulty, which required hospitalization to the

outside hospital. Blood cultures drawn at presentation

later grew streptococcus viridans. Transesophageal echo-

cardiogram was negative for endocarditis but revealed a

small patent foramen ovale. Lower extremity non-inva-

sive sonography showed bilateral DVTs. MRI of the

brain showed multiple subacute embolic foci. He was

transferred to our tertiary hospital 3 days after the initial

admission.

On arrival to our institution, CT scan of the chest was

performed, showing air pockets in the left atrial append-

age, left ventricle, and left superior pulmonary vein (Fig-

ure 1). A gastrografin swallow test showed extravasation

Successful Anesthetic Management for Surgical Repair of Atrio-Esophageal

Fistula Following Radiofrequency Ablation for Atrial Fibrillation

354

Figure 1. CT scan of the chest on arrival to our institution

showed air pockets in the left atrial appendage, left ventri-

cle, and left super i or pulmonary vein.

of the contrast from the mid-esophagus with rapid wash-

out. The patient experienced a progressive neurologic

decline, became somnolent and was emergently taken to

the operating room (OR) with a diagnosis of atrio-eso-

phageal fistula on hospital day 2.

In the OR, we placed two 14 gage peripheral intrave-

nous lines, a 9 French in troducer in right internal jugular

vein and a 20 gage left radial arterial line prior to the

induction of anesthesia. Cardiopulmonary bypass equip-

ment was brought to the OR on standby. The patient’s

heart rhythm was found to be atrial flutter/atrial fibrilla-

tion with marginal hemodynamics (heart rate 140 to 160,

blood pressure 100 - 120/60 - 80 mmHg on norepineph-

rine infusion up to 5 mcg/min from arrival to the OR

throughout the procedure). The patient was preoxygen-

ated with 100% oxygen and was induced with intrave-

nous 50 mg of ketamine, 250 mcg of fentanyl and 20 mg

of cisatracurium. Cricoid pressure was applied. An oral

cuffed 8.0 mmID endotracheal tube was inserted. Bron-

choscopy was performed to check whether the tracheal

and bronchial walls were intact, followed by replacement

of endotracheal tube with 39Fr right side double lumen

tube (DLT). The tube position was confirmed by flex

bronchoscopy. The patient was placed in the right lateral

decbitus position as surgical exposure was via a left tho-

racotomy.

Upon exploration, no pleural effusion was noted.

There w as inflammato ry adherenc e of the esophagu s just

superior to the inferior pulmonary vein. There was a tin y

contained mediastinal abscess between the wall of the

esophagus and the posterior left atrium. A small fistula

was identified. Both atrial and esophageal defects were

ligated and an intercostal muscle flap was placed be-

tween the atrial and esophageal repair. Once the surgeon

were satisfied with the repair, epicardial ultrasound was

performed to assess whether there was any air, blood clot

or gastric content in the heart prior to cardioversion;

there were no such findings. It was then decided to apply

5 Joules direct synchronous cardioversion, which was

delivered through internal paddles. The rhythm immedi-

ately converted to sinus rhythm. After the surgery com-

pleted, the patient was turned supine and DLT was chan-

ged back to a single lumen endotracheal tube. The patient

was transferred to ICU, intubated, and ventilated pr imar-

ily as a result of the patient’s depressed mental status.

In the ICU the patient was treated with intravenous an-

tibiotics and total parenteral nutrition. The patient recov-

ered slowly, was extubated on ICU day 2, was dis-

charged from ICU on ICU day 6 and was tran sferred to a

rehabilitation hospital. His neurologic status improved

slowly. Although he continued to suffer expressive apha-

sia, he was able to be independent with his activities of

daily living on discharge from the rehabilitation hospital

45 days after the surgery.

3. Discussion

Radiofrequency ablation for the treatment of atrial fibril-

lation is becoming more widely practiced in the United

States. Cases of atrio-esophageal fistula, a rare but usu-

ally fatal complication of this procedure have been re-

ported [1-10]. This is the first report of detailed anes-

thetic management for surgical repair of atrio-esophageal

fistula. We report our successful management and the

anesthetic consideration s .

The use of cardiopulmonary bypass for repair of atrio-

esophageal fistula has been described [4,5]. There is pro-

bably increased risk of embolization and bleeding when

cardiopulmonary bypass is used [4]. We had cardiopul-

monary bypass standby in the event cardiac standstill

was required for surgical repair. But, the atrio-esopha-

geal fistula was small and confined, and the surgical re-

pair was successful without cardiopulmonary bypass in

our case.

Transesophageal echocardiography (TEE) is common-

ly used in cardiac surgery. The decision not to perform a

TEE was made to avoid creating a larger defect in the

esophagus and/or causing bleeding in light of the diagno-

sis.

Induction was performed with ketamine to maintain

hemodynamics, keeping the patient’s spontaneous brea-

thing and thereby to avoid positive pressure ventilation

before airway was secured. Positive pressure ventilation

before securing airway would likely cause air emboliza-

tion from the esophagus to the left atrium through the

fistula. Once airway was secured, positive pressure ven-

tilation was carefully applied.

The biggest discussion between the surgeons and the

anesthesiologists was when to convert hemodynamically

Successful Anesthetic Management for Surgical Repair of Atrio-Esophageal

Fistula Following Radiofrequency Ablation for Atrial Fibrillation

355

unstable atrial fibrillation to sinus rhythm. The patient

became hemodynamically unstable shortly after arrival to

the OR. According to ACLS protocol, hemodynamically

unstable atrial fibrillation should be cardioverted. But in

this specific case, atrial fibrillation kept atrial pressure

low enough to avoid hemorrhage from the atria to the

chest or esophagus. Also converting to sinus rhythm in-

creases the likelihood of embolization of air, blood clot,

gastric contents in the left atrium into the brain or other

organs. And also the patient had had atrial fibrillatio n for

at least several days and the patient had very high risk for

thrombus formation due to factor V Leiden deficiency

and DVT. We did not know whether there was thrombus

or air in the left atria or how big it would be if thrombus

was present at this point. Cardioversion likely could have

ended up causing massive bleeding or embolization.

Hemodynamics was managed instead by infusing pheny-

lephrine and norepinephrine to maintain a systolic blood

pressure around 100 mmHg. Only once air in the atria

was suctioned, and no other air, blood clots or gastric

contents were detected by direct epicardial ultrasound

and the fistula was surgically repaired, caridoversion was

performed by directly applying paddles to the heart.

The patient was kept intubated and transferred to the

ICU due to the hemodyn amic instab ility and n eurolog ical

deterioration shown preoperatively which could impair

airway protection postoperatively. The patient was treat-

ed for sepsis with broad spectrum of antibiotics initially

to cover the likely bacterial species inh abiting esophagus.

The role of esophageal stent was considered intraope-

ratively. There was a successful case of esophageal stent

for atrio-esophageal fistula, using esophagoscopy [7],

even though most of the literature did recommend avoid-

ance of esophagoscopy [4-6,9]. But more data is needed

to determine which cases are indicated for esophageal

stent and esophagoscopy.

The key to managing these patients’ safety is the pre-

vention of massive bleeding and multiple air emboliza-

tion during the surgical repair and then later the postop-

erative management of sepsis and multiple organ failure,

which are the main causes of death from this complica-

tion.

4. Conclusion

We had a successful case in anesthetic management for

surgical repair of atrio-esophageal fistula with avoidance

of positive pressure ventilation before securing airway

and careful control of hemodynamics by delaying car-

dioversion to prevent massive bleeding as well as multi-

ple air embolization through the fistula.

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