Esophageal-left atrial fistula: An unsual cause

Abstract

A 55-year-old male presented with progressive dyspnea, swelling of legs and abdominal distension for past one week. Routine investigation showed presence of large pericardial effusion. Pericardiocentesis tapped a yellow colored sterile fluid with predominant polymorphs. However sequence of events following pericardiocentesis were unusual as patient developed stroke. MRI brain and CECT thorax were done. MRI brain showed small infarct and CECT showed presence of open safety pin eroding through esophagus and communicating with left atrium with thrombus and an air pocket within. Patient developed progressive encephalopathy and CT brain revealed multiple infarcts with pneumocephalus.

1. Case summary

A 50-year-old male presented with progressive shortness of breath, with swelling of limbs and abdominal distension for past 15 days. Blood investigations were normal, chest X-ray showed cardiomegaly. Echocardiogram showed presence of moderate pericardial effusion, with signs of tamponade and normal ventricular function. Subsequently pericardiocentesis was done, revealed yellow colored fluid (Fig. 1) with normal consistency and not foul smelling. Fluid analysis was negative for gram staining, KOH mount, AFB and malignant cells. Biochemical examination: Total cell count: 10,000/cumm, Polymorphs: 90%, occasional RBC, Sugar: 39 mg%, protein: 2.9 gm% and fluid ADA: 28.4 U/L. Fluid was sent for culture. One hour after pericardiocentesis patient developed left sided hemiplegia. MRI brain and CECT chest was done. MRI brain was suggestive of small infarct and CECT chest showed presence of an open safety pin eroding through esophagus (Fig. 2) and communicating with left atrium and small thrombus with an air pocket in LA (Fig. 3). Following above investigations patient condition deteriorated. His neurological condition progressed to encephalopathy. CT brain was done in consultation with neurologist and showed presence of multiple infarct and pneumocephalus. Patient deteriorated rapidly and could not be saved. Fluid culture was negative at 24 h and 72 h.

Fig. 1.

Pericardial fluid.

Fig. 2.

Reconstructed CT image. Presence of safety pin in the esophagus. Pigtail catheter in the pericardium.

Fig. 3.

Presence of thrombus (big arrow) and a small air pocket (small arrow) in left atrium (star) and air in the mediastinum (block, white arrow). Bilateral pleural effusion.

2. Discussion

Esophageal-left atrial fistula carries a poor prognosis. The common cause for the above condition is malignancy and presently increasing use of radiofrequency ablation for atrial fibrillation. It is characterized by upper GI bleeding, purulent pericarditis, chronic dysphagia and neurological symptoms.¹ It is mostly diagnosed intraoperatively or postmortem. Presence of air and a thrombus on echocardiogram known as “aquarium sign” is characteristic of esophageal-LA communication.² However the above finding was seen on CT scan in our patient.

Synder and colleagues have reviewed the limited literature on the above condition and identified following risk factors: malignancy, radiotherapy and stricture dilatation.¹ Early diagnosis of this entity can be challenging because of its low incidence and any classic sign other than GI bleed. A recent case of left atrial–esophageal communication following radiofrequency ablation presented with minor hematemesis after four weeks. Endoscopy revealed presence of thrombus in esophagus which was sealing the fistula.³

This is an unusual case of left atrial and esophageal communication. The above patient's condition deteriorated following pericardiocentesis and MRI. The possible explanation could be that following pericardiocentesis, the esophagus and LA came closer and therefore the injury from safety pin must have increased. Subsequently MRI could have created movement of the safety pin, disturbing the possible one way valve and increasing the injury leading to thrombus and air embolism to brain.

Atrioesophageal communication following radiofrequency ablation is a known complication and results from collateral damage to esophagus. However the reported incidence in literature is 0.01–0.2%.^4,5 The natural history is not well defined. Cummins et al reported a mortality rate of 100% in their case series of nine patients.⁶ Early surgical intervention and prolonged antibiotics is the key to survival. All patients who did not undergo surgery expired except for one who was managed by esophageal stenting. Mortality rate was 40% in patients who underwent surgery. The overall mortality rate is 67%.⁷

The above case highlights a rare case and emphasizes on thinking out of box.

Conflicts of interest

All authors have none to declare.