Mackle Trisha, Pistawka Kevin
Department of Emergency Medicine, University of British Columbia, Kelowna, British Columbia, Canada.
Department of Medicine, Division of Cardiology, University of British Columbia, Kelowna, British Columbia, Canada.
J Emerg Med. 2017 Jul;53(1):e1-e4. doi: 10.1016/j.jemermed.2017.03.025. Epub 2017 May 10.
Atrioesophageal fistula (AEF) is a rare and highly fatal complication of ablation procedures for atrial fibrillation. We report a diagnostically challenging case of AEF that highlights the unfortunate outcome that can be expected when this condition is not promptly diagnosed and managed accordingly. The varied clinical presentations are reviewed and recommended diagnostic and management approaches are presented.
A 79-year-old female who was 5 weeks post-ablation presented to a community emergency department with chest pain and a transient episode of left-arm weakness. Troponin was mildly elevated, but other investigations, including thoracic and head computed tomography (CT) were normal. During the course of the next few days in hospital, the diagnosis of AEF became apparent, as the patient developed a fever and recurrent episodes of neurologic deficits along with blood cultures that yielded upper gastrointestinal flora. The patient was urgently transferred to a tertiary center where repeat thoracic CT confirmed the diagnosis, but she succumbed to an intracranial bleed before definitive surgical management could be performed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case is presented to increase awareness among emergency physicians of this fatal condition that is increasing in incidence as ablation procedures become more mainstream. The diagnosis can be challenging, given that presenting symptoms are often variable and nonspecific. To complicate matters further, performing certain diagnostic tests and interventions can prove fatal in this particular patient population. Survival in these unfortunate cases is highly dependent on initiating a prompt and appropriate diagnostic workup, followed by rapid surgical intervention.
心房食管瘘（AEF）是心房颤动消融手术中一种罕见且致死率很高的并发症。我们报告一例诊断颇具挑战性的AEF病例，该病例凸显了若未及时诊断并采取相应处理措施可能出现的不幸后果。本文回顾了AEF多样的临床表现，并介绍了推荐的诊断和处理方法。
一名79岁女性，在消融术后5周因胸痛和左臂短暂无力就诊于社区急诊科。肌钙蛋白轻度升高，但包括胸部和头部计算机断层扫描（CT）在内的其他检查均正常。在住院后的几天里，AEF的诊断逐渐明确，因为患者出现发热、反复的神经功能缺损发作，且血培养结果显示为上消化道菌群。患者被紧急转至三级医疗中心，重复胸部CT检查确诊了该病，但在能够进行确定性手术治疗之前，她死于颅内出血。
为什么急诊医生应该了解这个情况？：本病例旨在提高急诊医生对这种致命疾病的认识，随着消融手术越来越主流，其发病率正在上升。鉴于临床表现往往多样且不具特异性，诊断可能颇具挑战性。更复杂的是，对这一特定患者群体进行某些诊断检查和干预可能是致命的。在这些不幸的病例中，生存高度依赖于及时启动恰当的诊断检查，随后进行快速的手术干预。
