CTICasesAtrioesophageal Fistula After Atrial Fibrillation Ablation with Embolic Strokes
Imaging findings
Following atrial fibrillation ablation, a small focus of gas adjacent to a pulmonary vein ostium in the left atrium is identified on an outside CT, initially raising concern for an atrioesophageal fistula; correlating imaging with oral contrast confirms gas tracking outside the adjacent esophagus. The patient subsequently developed acute embolic strokes without any macroscopic air emboli identified, and a small pericardial defect with associated adhesions was found and repaired surgically with a muscle flap. Incidentally, abdomen/pelvis and chest CT also show numerous smooth, uniform pulmonary cysts and a probable renal angiomyolipoma.
Key takeaways
A tiny focus of gas near a pulmonary vein ablation site in the left atrium is a well-recognized harbinger of atrioesophageal fistula, typically presenting in the two-to-four-week post-ablation window with sepsis and embolic strokes from septic/thrombotic debris rather than visible air emboli -- endoscopic instrumentation of the esophagus should be avoided given the risk of catastrophic air embolization, and the incidentally noted pulmonary cysts with a probable angiomyolipoma raise suspicion for underlying lymphangioleiomyomatosis and tuberous sclerosis.
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