CTICasesAtrioesophageal Fistula Post-Atrial Fibrillation Ablation
Imaging findings
Multidetector CT scans of three separate patients demonstrate various stages of atrioesophageal fistula development following left atrial radiofrequency ablation. Findings include free air bubbles in the left atrium and systemic arterial circulation (cerebral air embolism), localized collections of mediastinal air between the posterior left atrial wall and esophagus, and eccentric air or contrast extravasation along the esophageal wall. High-resolution CT and esophagography show a broad-based, form-fitting esophageal ulcer directly abutting the back of the left atrium.
Key takeaways
Atrioesophageal fistula is a rare but highly lethal complication of catheter ablation for atrial fibrillation, resulting from thermal injury to the anterior esophageal wall. Radiologists must maintain a high index of suspicion for subtle signs such as ectopic mediastinal air, esophageal wall thickening, or left atrial air in patients presenting with neurologic symptoms, fever, or chest pain after ablation. Rapid surgical intervention is required as conservative management carries a near-100% mortality rate.
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