Septic Thromboembolic Stroke via Atrial-Esophageal Fistula as a Delayed Complication of Cardiac Ablation (P6.018)

Objective: To report a rare presentation of septic thromboembolic stroke as a delayed complication of cardiac ablation. Background: Cardiac ablation (CA) for atrial fibrillation (AF) is indicated when medical management fails. Atrial esophageal (A-E) fistula is a rare but potentially fatal complication of the procedure. While known to cause pneumomediastinitis, GI bleed or cerebral air embolism, rarely a delayed septic thromboembolic stroke may be the initial presentation. Case Report: A 75-year-old male was admitted following acute onset of left-sided deficits. Neurologic assessment confirmed severe hemiparesis, hemiparesthesias, and hemianopia. A STAT computed tomography (CT) brain scan showed a right occipitoparietal watershed infarct (FIGURE 1). Relevant history included a CA procedure 41 days prior to presentation. In the post-operative period, CT chest with contrast was ordered due to complaint of dysphagia, which was negative for pneumomediastinum or intra-atrial air. Shortly after admission the patient became febrile and stuporous requiring intubation and broad-spectrum antibiotics. Blood cultures revealed gram-positive cocci in chains. Brain MRI showed bihemispheric non-hemorrhagic infarcts with associated gyral enhancement on post-contrast images (FIGURE 2). Transthoracic echocardiogram was negative for vegetations or intra-atrial shunt but transesophageal echocardiogram was suggestive of thrombus. Repeat brain MRI showed new bilateral extensive strokes (FIGURE 3) and decision by family was to withdraw care. Autopsy revealed a left atrio-esophageal fistula with associated intra-atrial fibrinopurulent necrosis of atrial myocardial fibers associated with suppurative inflammation, and subacute inflammation within the intervening periesophageal adventitium, with bacteria and fungal hyphae, along with features consistent with cerebral thromboembolic infarcts. (FIGURES 4, 5). Conclusions: In the perioperative period following CA, diagnostic testing to rule out the often fatal complication of an A-E fistula may be non-revealing. A high index of suspicion should nonetheless be maintained that an occult A-E fistula is a cause of delayed presentation of septic cerebral thromboembolism. Disclosure: Dr. Derani has nothing to disclose. Dr. Chaudhry has nothing to disclose. Dr. Sachdeva has nothing to disclose. Dr. Long has nothing to disclose. Dr. Hughes has nothing to disclose. Dr. Kumar has nothing to disclose. Dr. Chang has nothing to disclose. Dr. Razak has nothing to disclose.