Atrioesophageal Fistula: imaging for a definitive diagnosis

Aim: Atrial fibrillation is a common arrhythmia, with a prevalence of 37.574 million cases worldwide. Atrioesophageal fistula is a rare but potentially fatal complication of ablation of atrial fibrillation developing up to 60-days post-ablation with a prevalence of 0.07% to 0.25%, and a 63% mortality. While chest CTs are abnormal in most of these patients (76%-93%), definitive atrioesophageal fistula is noted in only 23-35% of cases, complicating pre-intervention diagnosis. Surgical repair of the left atrial and primary esophageal defect is essential for these patients, resulting in reduced mortality compared to nonsurgical management (33.71% vs. 94.19%). Methods: Our case series and comprehensive review of the literature highlights the diagnostic and treatment challenges of atrioesophageal fistula. Results/Conclusions: For symptomatic patients within 60-days post-ablation, IV contrast-enhanced helical chest CT with thin section collimation as initial imaging and axial reconstruction utilizing a 1mm-mm detector with sagittal and coronal reformats should be completed to allow for optimal identification of abnormalities consistent with atrioesophageal fistula. Patients with neurologic symptoms with the presence of pneumocephalus, infarcts involving one or more vascular territories, or diffuse air emboli that are highly suggestive of atrioesophageal fistula, warrant a chest CT with IV contrast to evaluate the presence of AEF. An initial unremarkable chest CT does not rule out atrioesophageal fistula and repeat chest CT with IV contrast within 1-3 days increases the likelihood of a definitive AEF diagnosis. Surgery is the only recommended management in patients with atrioesophageal fistula who are clinically stable enough to endure the procedures.