1. ATRIAL ESOPHAGEAL FISTULA SECONDARY TO ABLATION FOR ATRIAL FIBRILLATION: A CASE SERIES AND REVIEW OF THE LITERATURE 1 Lily K. Fatula, BS; 1,2 William D. Bolton, MD; 1,2 Barry R. Davis, MD; 1,2 James E. Stephenson, MD; 1,2 Sharon Ben-Or, MD. 1 University of South Caroline School of Medicine Greenville, Greenville, SC ; 2 Division of Thoracic Surgery, Greenville Health System, Greenville, SC Background In an era where atrial fibrillation (AF) is increasingly diagnosed, catheter ablation has become the preferred treatment in patients with AF refractory to medical or electrical therapy. Although catheter ablation is considered a safe and effective treatment, left atrial esophageal fistula (LAEF) is an unusual but possibly fatal outcome. Multiple reports of LAEF have reported rapid progression from symptoms to death. As a result, recognition and subsequent intervention is imperative in caring for these patients. Objective The aim of this paper is to describe presenting symptoms, diagnostic modalities, and survival outcomes in patients with LAEF secondary to catheter ablation for AF. Discussion According to the literature, patients with LAEF primarily present with fevers, neurological deficits, hematemesis, altered mental status, and/or chest pain; similar presenting symptoms were also seen our patients. With regards to diagnostic modalities, chest CT and head CT are the leading methods reported. 1 In our experience, head and chest CT also proved to be the most accurate diagnostic tools. Reported mortality rates associated with LAEF are high (40-80%). However, multiple reports suggest that speed of diagnosis and subsequent treatment could increase a patient’s chance of survival. 1-3 Table 1: Description of Literature vs. Our Experience Literature review 1 N=53 Patient A Patient B Gender Male, N (%)39 (73)XX Age, years54 ± 135777 Post Procedure Date, mean days (range) 20 (2-60)31*21 Presenting Symptom(s), N Neurological34XX Fevers44X Chest Pain11 Hematemesis19 Altered Mental Status15X Initial Diagnostic Modality CT of the Chest27X CT of the head15X EGD3 ECHO14 MRI of the brain4 Treatment, N (%) Surgical26 (49.1)XX Mortality, N (%)30 (56.6)XX 1 Adapted from Chavez et al. Open Heart. 2015; 2:e000257 *Presented to other facilities before ours Surgical Treatment & Cause of Death Patient A Presented 31 days post ablation and underwent CT scan and ECHO which showed the LAEF (Figs. A, B) Hours after presentation, underwent sternotomy, cardiopulmonary bypass, and patch closure of the left atrial fistula. Had a complicated post-operative course, including sepsis and cardiogenic shock which required a mediastinal exploration, washout, and insertion of intra-aortic balloon pump. The following day,a left thoracotomy, intercostal muscle flap, and EGD were performed. Developed multi-organ failure and was unable to be weaned off the ventilator. The family decided to withdraw care and the patient expired the same day (POD 28). Patient B Presented to our facility 21 days post AF ablation with left arm weakness and altered mental status. A CT scan of the chest and brain (Figs. C, D) showed pneumocephalus, and the patient underwent right thoracotomy, total esophagectomy, intercostal muscle flap, closure of LAEF, and cervical esophagostomy placement. Ultimately the LAEF closure dehisced and the patient developed acute respiratory failure and cardiac tamponade which lead to cardiopulmonary arrest. The patient was intubated and underwent an ultrasound guided pericardiocentesis. After this procedure no cardiac activity was seen and the patient expired (POD 10). References 1.Chavez P et al. Open Heart 2015;2:e000257. doi:10.1136/openhrt-2015-000257 2.Cummings, J. (2006). Brief Communication: Atrial-Esophageal Fistulas after Radiofrequency Ablation. Annals of Internal Medicine, 144(8), 572-574 3.Pappone, C. (2004). Atrio-Esophageal Fistula as a Complication of Percutaneous Transcatheter Ablation of Atrial Fibrillation. American Heart Association. Figures: A) CT scan of chest showing fistula ; B) ECHO showing fistula; C) CT scan of chest showing air and contrast in left atrium; D) MRI of head showing air emboli A CD B Conclusion Based on the literature, as well as our limited experience, we recommend a chest CT be immediately performed on patients presenting with the described symptoms following recent AF ablation. Contact: Lbarkin@email.sc.edu