Oesophago-pericardial fistula
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* Michael Pope
* Andre Briosa e Gala
* Andrew Cox
* Timothy Betts

Editor – regarding Dutton *et al*'s presentation of fatal oesophago-pericardial fistula with cerebral air embolism after elective atrial fibrillation ablation,1 awareness of this complication is high amongst cardiac electrophysiologists but less so among other physicians. We therefore commend the authors for highlighting this tragic case and we would like to add some complementary insights.

Atrio-oesophageal fistulation should be considered the end stage of a spectrum that encompasses superficial oesophageal thermal injury, ulceration and perforation leading to oesophago-mediastinal, pericardial and atrial fistulation.2 As the authors point out, a high clinical suspicion is required. This is particularly important for early diagnosis, which will dictate appropriate management. Any presentation between 5 days and 5 weeks following left atrial ablation with a recurrence of atrial fibrillation (AF), chest pain, gastro-oesophageal symptoms, fever and/or leukocytosis should warrant consideration. The development of systemic emboli represents advanced pathology and a very poor prognosis. This pattern may be misinterpreted as endocarditis but history of recent left atrial ablation (particularly AF ablation) should prompt consideration of oesophageal injury and trans-oesophageal echocardiography must be avoided.

The initial investigation of choice is computed tomography (CT) with intravenous and oral contrast. If oesophageal perforation is excluded then endoscopy can be performed to exclude significant oesophageal injury.3 This is not recommended prior to CT as peri-procedural insufflation of the oesophagus in the presence of an oesophago-pericardial fistula can result in pneumopericardium and haemodynamic collapse.

Management is then guided by the presence or absence of mediastinitis. Although the authors are correct to point out the poor outcomes of medical management and stent placement, this is largely in patients with delayed diagnosis and a systemic inflammatory response suggestive of established mediastinitis.4 Endoscopic surveillance allows the detection of oesophageal thermal injury prior to perforation and early stent placement in the event of progression. Similarly when fistulation is present without evidence of mediastinitis, stenting may be an effective option.3 Importantly, where stent implantation is performed in the context of an oesophago-pericardial fistula a pericardial drain should be placed in advance to prevent iatrogenic pneumopericardium. If an atrio-oesophageal fistula or any evidence of mediastinitis are detected then surgical intervention is mandated.

Fortunately, this is a rare complication.5 A high degree of clinical suspicion is crucial for early diagnosis and we would encourage discussion with cardiac electrophysiology colleagues in all patients presenting to hospital following a catheter ablation procedure for atrial fibrillation particularly in the context of chest pain, fever and/or leukocytosis.

*   © 2019 Royal College of Physicians

## References

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    [Abstract/FREE Full Text](http://www.rcpjournals.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6MTI6ImNsaW5tZWRpY2luZSI7czo1OiJyZXNpZCI7czo4OiIxOS80LzMzMSI7czo0OiJhdG9tIjtzOjI5OiIvY2xpbm1lZGljaW5lLzE5LzUvNDMxLjIuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

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    [Abstract/FREE Full Text](http://www.rcpjournals.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NjoiY2lyY2FlIjtzOjU6InJlc2lkIjtzOjY6IjMvMS8zMiI7czo0OiJhdG9tIjtzOjI5OiIvY2xpbm1lZGljaW5lLzE5LzUvNDMxLjIuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9)