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Title: Challenges and limitations in the diagnosis of atrio-esophageal fistula.
Austin Authors: Ha, Francis J;Han, Hui-Chen ;Sanders, Prashanthan;Teh, Andrew W ;O'Donnell, David ;Farouque, Omar ;Lim, Han S 
Affiliation: Austin Health, Heidelberg, Victoria, Australia
University of Melbourne, Melbourne, Victoria, Australia
Centre for Heart Rhythm Disorders (CHRD), South Australia Health and Medical Research Institute (SAHMRI), University of Adelaide and Royal Adelaide Hospital, South Australia, Australia
Northern Health, Melbourne, Victoria, Australia
Issue Date: 30-Mar-2018 2018-03-30
Publication information: Journal of cardiovascular electrophysiology 2018; 29(6): 861-871
Abstract: Atrio-esophageal fistula (AEF) is a dire complication of atrial fibrillation ablation. The diagnostic yield of computed tomography (CT) chest, the role and timing of repeat testing, and the value of other investigations in the diagnosis of AEF is uncertain. We systematically reviewed published AEF cases to evaluate radiological, bedside and biochemical investigations for AEF (registered on PROSPERO [CRD42017077493]). Eighty-seven articles with 126 patients (median age, 59 years; male, 71%) were included in the analysis. CT chest was performed in 88% (111/126) and was abnormal in 87%. A clear diagnosis of AEF (fistula/perforation) was only detected in 35% (34/97). Other major findings included free air in mediastinum (26%), left atrium (LA) or LA wall (24%). In 11 patients with normal/non-specific initial CT chest, major abnormalities were detected in 91% (10/11) of repeat CT chest performed 6 days (median; range, 4-22) after initial scan. Initial CT head was normal in 51%; diffuse air emboli was identified in 79% (22/28). Initial trans-thoracic echocardiography was normal in 61% of cases. The spectrum of radiological abnormalities included Air (mediastinum/LA), Effusion (pleural/pericardial), Fistula/Perforation, and Thickening (esophagus/LA) - "AEF-Tests". Esophagram demonstrated contrast extravasation in 87% (13/15). Blood culture was consistently positive (100%; 28/28), particularly for streptococcus species (93%; 26/28). The diagnosis of AEF remains challenging. Clinicians should be aware of the limitations in the yield of CT chest, the variety of major abnormalities reported, the need for repeat testing, unique brain imaging findings, and the importance of positive blood cultures and raised inflammatory markers. This article is protected by copyright. All rights reserved.
DOI: 10.1111/jce.13494
ORCID: 0000-0003-3206-5725
PubMed URL: 29603477
Type: Journal Article
Subjects: atrial fibrillation
atrio-esophageal fistula
catheter Ablation
computed tomography
Appears in Collections:Journal articles

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