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Ann Thorac Surg 2003;76:281-283
© 2003 The Society of Thoracic Surgeons
a Departments of Cardiovascular Surgery, Istanbul Memorial Hospital, Istanbul, Turkey
b Department of Cardiology, Istanbul Memorial Hospital, Istanbul, Turkey
c Department of Gastroenterology, Istanbul Memorial Hospital, Istanbul, Turkey
Accepted for publication December 23, 2002.
* Address reprint requests to Dr Demirsoy, Necip Bey Sok. Melen Apt., 6, 681010, Ac
badem-Istanbul, Turkey
e-mail: ergundemirsoy{at}hotmail.com
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A 58-year-old white woman was admitted to the surgical ward with rheumatic aortic and mitral valve disease complicated by atrial fibrillation for 6 years. Detailed transesophageal echocardiographic (TEE) evaluation revealed severe aortic stenosis and regurgitation, mitral and tricuspid valve regurgitation due to annular dilatation, biatrial enlargement and mild left ventricular dysfunction. Left atrial (LA) diameter was 78 mm, calculated pulmonary artery pressure was 58 mm Hg. Angiocardiography demonstrated ostial stenosis of the right coronary artery of about 80%.
During operation TEE was not performed. The esophagus was occupied solely by a nasogastric tube. A standard median sternotomy and bicaval cardiopulmonary bypass was instituted and the mitral valve was visualized through a left atriotomy. The Cobra RF System (Boston Scientific, Boston, Natick, MA) catheter was used to create ablation lines at 80°C for 120 seconds. To isolate the right pulmonary vein group we created a C-shaped line as a continuation of the left atriotomy incision and thus encircled these two right pulmonary veins. The two left pulmonary veins were encircled in a second maneuver, and both circles were then connected by a transverse line. Another line was also created to connect the left pulmonary vein circle to the midportion of the posterior mitral annulus. This was done using cold cardioplegia to protect the posterior sulcus. All of these procedures were performed as we were trained by Dr Melo[1]. The ablation procedure was performed before replacement of both the mitral and aortic valves with bileaflet mechanical valves (St Jude Medical, Inc, St Paul, MN). A De Vega repair of the tricuspid valve was also performed to reduce annular dilatation. The left atrial appendage orifice was oversewn before the closure of the left atrium. Finally, an aorto–right coronary artery bypass was performed with a saphenous vein graft.
Postoperative recovery was complicated only by paroxysmal atrial fibrillation–flutter, which was treated with amiodarone. The patient was discharged on postoperative day 7 while AF was alternating with sinus rhythm. Amiodarone was prescribed and restoration of a definitive sinus rhythm was expected.
Twenty-two days after the operation, the patient was readmitted with fever (39°C), shivering, and numbness in the right arm. The latter was spontaneously relieved after hospitalization. Transthoracic echography demonstrated normal functioning of the prosthetic valves, and the presence of a thrombus was suspected in the left atrium wall. Transesophageal echocardiography confirmed a thrombus near the appendage remnant also. The patient’s neurologic condition suddenly deteriorated to an unconscious state and immediately transferred to the operating room. Rapidly cardiopulmonary bypass was instituted and the thrombus on the appendage remnant and around the pulmonary vein orifices was cleared out. After careful inspection of the mitral valve prosthesis, the left atrium was closed and the patient was weaned from bypass without difficulty. Sudden massive bleeding from the nasogastric tube developed before the chest was closed. Urgent esophagoscopy revealed a bleeding laceration of 15 mm diameter on the anterior wall of the esophagus 33 cm from the incisors (Fig 1). The patient was put on crush cardiopulmonary bypass again. Gas bubbles were detected in the left atrium probably resulting from the esophagoscopy. Air was passing through this laceration into the left atrium (between the two circles created by the ablation lines around the right and left pulmonary veins), which was not seen during the first attempt. The laceration was repaired with a pericardial patch reinforced with sutures. The esophageal bleeding stopped, and the nasogastric tube was kept in place in case of an eventual esophageal intervention. A cerebral CT scan performed 24 hours later showed wide ischemic lesions on both hemispheres, indicating cerebral emboli. The patient never recovered with regard to her neurologic status and she died of multiorgan failure 20 days after a second intervention. Her family did not consent to an autopsy.
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In the case reported here, the esophageal bleeding and the endocarditis were treated successfully, but the patient died from neurologic complications. Whether these were caused by migration of thrombus in the left atrium or by air pumped by esophagoscopy, or both, is impossible for us to determine. In the fatal case reported by Mohr and associates [3], massive cerebral infarction resulting from air embolism was believed to have been caused by esophagoscopy.
In conclusion, we believe that atrio-esophageal fistula after RF ablation is a potentially lethal complication. The mechanism is still open to debate, and further experience is required to avoid esophageal injury.
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