Rapid detection and successful treatment of esophageal perforation after radiofrequency ablation of atrial fibrillation: lessons from five cases.
BACKGROUND
The aim of the study was to identify criteria for rapid recognition and successful treatment of esophageal perforation after radiofrequency ablation for atrial fibrillation (AF).


RESULTS
Esophageal perforation occurred in five patients after intraoperative (n = 4) or percutaneous (n = 1) AF ablation. Patients presented with high fever (n = 3) or severe chest/epigastric pain (n = 2) 8-28 days after ablation. WBC count was elevated at presentation in all patients (15,460 +/- 2,910/muL), CRP showed a delayed rise. Thoracic CT detected free air in all. Neurologic complications occurred in three cases (60%) with a delay of 5-40 hours after first symptoms. Only one (20%) developed neurologic complications within the first 24 hours. Two patients (40%) died before surgery could be performed. In both, time from symptom onset to diagnosis was significant (24 and 36 hours). Three patients (60%) underwent esophageal resection and survived. In two of them, treatment was rapid with time from symptoms to surgery of 24 hours; they had favorable outcome. In the third surviving patient, surgery was late (5 days after first symptoms); permanent neurologic residues remained.


CONCLUSIONS
The leading symptom of esophageal perforation is high fever or severe chest/epigastric pain. Fever is not necessarily present. Leukocytosis is the earliest and most sensitive laboratory marker, thoracic CT the most valuable diagnostic examination. The dramatic neurologic complications occur with a delay of at least a few hours after first symptoms. Immediate surgery may prevent neurologic complications and could possibly result in a high survival rate without residues. Delay of treatment seems to have devastating results.
Dagres
Nikolaos
N
University of Athens, Second Cardiology Department, Attikon University Hospital, Athens, Greece. nikolaosdagres@yahoo.de
Kottkamp
Hans
H
Piorkowski
Christopher
C
Doll
Nicolas
N
Mohr
Friedrich
F
Horlitz
Marc
M
Kremastinos
Dimitrios Th
DT
Hindricks
Gerhard
G
D000328:Adult; D000368:Aged; D001281:Atrial Fibrillation / Q000175:diagnosis* / Q000503:physiopathology; D017115:Catheter Ablation / Q000009:adverse effects*; D004939:Esophageal Perforation / Q000150:complications / Q000175:diagnosis* / Q000601:surgery*; D005260:Female; D005334:Fever / Q000209:etiology; D006801:Humans; D007431:Intraoperative Complications / Q000175:diagnosis / Q000601:surgery; D007964:Leukocytosis / Q000209:etiology; D008297:Male; D008875:Middle Aged; D013997:Time Factors