Bunch T Jared, Nelson Jennifer, Foley Tom, Allison Scott, Crandall Brian G, Osborn Jeffrey S, Weiss J Peter, Anderson Jeffrey L, Nielsen Peter, Anderson Lars, Lappe Donald L, Day John D
Division of Cardiovascular Disease, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
J Cardiovasc Electrophysiol. 2006 Apr;17(4):435-9. doi: 10.1111/j.1540-8167.2006.00464.x.
Left atrial catheter ablation (LACA) has emerged as a successful method to eliminate atrial fibrillation (AF). Recent reports have described atrio-esophageal fistulas, often resulting in death, from this procedure. Temporary esophageal stenting is an established therapy for malignant esophageal disease. We describe the first case of successful temporary esophageal stenting for an esophageal perforation following LACA.
A 48-year-old man with symptomatic drug refractory lone AF underwent an uneventful LACA. Fifty-nine ablations with an 8-mm tip ablation catheter (30 seconds, 70 Watts, 55 degrees C), as guided by 3-D NavX mapping, were performed in the left atrium to isolate the pulmonary veins as well as a left atrial flutter and roof ablation line. In addition, complex atrial electrograms in AF and sites of vagal innervation were ablated. Two weeks later, he presented with sub-sternal chest pain, fever, and dysphagia. A chest CT showed a 3-mm esophageal perforation at the level of the left atrium with mediastinal soiling and no pericardial effusion. An urgent upper endoscopy with placement of a PolyFlex removable esophageal stent to seal off the esophago-mediastinal fistula was performed. After 3 weeks of i.v. antibiotics, naso-jejunal tube feedings, and esophageal stenting, the perforation resolved and the stent was removed. Over 18 months of follow-up, there have been no other complications, and he has returned to a physically active life and remains free from AF on previously ineffective anti-arrhythmic drugs.
Early diagnosis of esophageal perforations following LACA may allow temporary esophageal stenting with successful esophageal healing. Prompt chest CT scans with oral and i.v. contrast should be considered in any patient with sub-sternal chest pain or dysphagia following LACA.
左心房导管消融术（LACA）已成为消除心房颤动（AF）的一种成功方法。最近的报告描述了该手术导致的心房食管瘘，常导致死亡。临时食管支架置入术是治疗恶性食管疾病的既定疗法。我们描述了首例LACA术后食管穿孔成功进行临时食管支架置入术的病例。
一名48岁有症状的药物难治性孤立性AF男性患者接受了顺利的LACA手术。在三维NavX标测引导下，使用8毫米尖端消融导管在左心房进行了59次消融（30秒，70瓦，55摄氏度），以隔离肺静脉以及左心房扑动和顶部消融线。此外，还对房颤时的复杂心房电图和迷走神经支配部位进行了消融。两周后，他出现胸骨后胸痛、发热和吞咽困难。胸部CT显示左心房水平有一个3毫米的食管穿孔，伴有纵隔污染，无心包积液。紧急进行了上消化道内镜检查，并放置了PolyFlex可移除食管支架以封闭食管纵隔瘘。经过3周的静脉抗生素治疗、鼻空肠管喂养和食管支架置入，穿孔愈合，支架移除。在超过18个月的随访中，没有出现其他并发症，他已恢复积极的生活，并且在之前无效的抗心律失常药物治疗下仍未发生房颤。
LACA术后食管穿孔的早期诊断可能允许进行临时食管支架置入术并成功实现食管愈合。对于任何LACA术后出现胸骨后胸痛或吞咽困难的患者，应考虑及时进行口服和静脉造影剂的胸部CT扫描。
