1831 Pericardioesophageal Fistula Formation Following Ventricular Tachycardia Ablation: Case Presentation With Discussion of Incidence and Treatment

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The American Journal of Gastroenterology


INTRODUCTION: Cardioesophageal fistulas following radiofrequency ablation (RFA) for atrial fibrillation is a rare but increasingly recognized complication of the procedure with an estimated annual incidence rate of 0.03-0.04%. While atrioesophageal fistulas require surgical management, pericardialesophageal fistulas can often be conservatively managed. The fistula formation is believed to be due to the inflammatory cascade initiated from thermal injury and subsequent degradation of tissue boundaries. Though reported following atrial ablation, it has not been reported with ventricular ablation. Here, we present a case of pericardioesophageal fistula following RFA for ventricular tachycardia.

CASE DESCRIPTION/METHODS: 61-year-old male presented to the emergency department complaining of fever, chest pain and dyspnea following inferolateral wall ablation and scar homogenization two weeks prior. He had a history of cardiomyopathy with AICD placement and refractory ventricular tachycardia due to ischemic heart disease. CT angiogram ruled out PE but demonstrated a pneumopericardium, later confirmed by echocardiogram. He subsequently developed signs of sepsis with profound hypotension requiring pressor support and underwent a pericardial window and indwelling pericardial drain placement. Due to fibrinous septations, tPA was infused to facilitate the purulent drainage. Fluid cultured from the pericardial window grew Staphylococcus epidermis and gram-negative bacilli. EGD was preformed with a 2 cm diameter pericardioesophageal fistula 4 cm above the GE junction and 36 cm distal to the incisors. He had a fully covered esophageal stent placed given poor nutritional status and poor surgical candidacy. His hospital course was further complicated by vent dependent respiratory failure, acute renal failure, recurrent DVTs with an upper GI bleed due to a contained rupture of an esophageal hematoma necessitating the placement of an IVC filter. Follow-up endoscopy two months following placement demonstrated stent migration but a healed pericardioesophageal fistula.

DISCUSSION: This case demonstrates the importance of considering pericardioesophageal fistula as a complication of ventricular ablation. Treatment options are variable and they are often managed endoscopically as a temporizing measure until surgery can be safely performed. Here, we report the first case, to our knowledge, of pericardioesophageal fistula following ventricular ablation successfully managed with supportive measures.



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American College of Gastroenterology Annual Meeting, San Antonio TX, October 25-30, 2019.

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