atrial - esophageal fistula ( aef ) is a rare severe disease , which may be associated with radiofrequency catheter ablation ( rfca ) of atrial fibrillation ( af ) or intraoperative radiofrequency ablation of atrial fibrillation ( iraaf ) .
we presented a case of a 67-year - old man with aef following rfca treated with esophageal stenting and surgical repair , and then reviewed literatures about aef to explore the appropriate treatment options .
a 67-year - old man , who had coronary heart disease , af , and heart failure , was admitted because of dyspnea and rapid af .
. then rfca of rf was to perform wide area circumferential ablations to achieve pulmonary vein isolation using a 3.5  mm tip electrode on a d - curved thermocool catheter through agelis sheath .
the lesions were applied for 30 to 60  s with 30 to 30 walter .
18 days after the procedure , the patient was admitted to local hospital with complaint of chest discomfort and fever for 1 day .
his temperature was 41c , white blood count ( wbc ) 5.2    10/l , and high sensitivity c
, physical examination revealed that his temperature was 37.9c , blood pressure was 99/73  mm hg , and pulse rate was 78 beats / min .
the initial laboratory studies showed n - terminal pro brain natriuretic peptide ( nt - probnp ) 1550.00 pg / ml , alanine aminotransferase 21 u / l , cardiac troponin i 3.95  g / l , wbc 10.58    10/l , neutrophil 97.2% , hscrp 26.0  mg / l , and fecal occult blood 3 + .
contrast - enhanced ct ( cect ) showed suspicious thrombus in left atrial appendage ( fig .
contrast - enhanced computed tomography showed suspicious thrombus in left atrial appendage ( indicated by red arrow ) .
patient was asked to fast with gastrointestinal ( gi ) decompression , and used antibiotic , imipenem / cilastatin and linezolid , to control infections .
he regained consciousness from the next day after admitting our institution , but he still had repeated epileptic seizures .
cerebral magnetic resonance imaging ( mri ) was performed and showed lacuna infarctions ( fig .
emergency esophagogastroduodenoscopy ( egd ) showed a small and deep ulcer at 30  cm from incisors .
the esophagus was stented with self - expanding , polyester - covered , length 100  mm , width 18  mm ( nanjing micro - tech , nanjing , china ) ( fig .
3 ) . in the following days , wbc counts and hscrp level decreased , epileptic seizures went away .
but the symptom of acid reflux occurred from the 5th day after esophageal stenting when he ate fluid food . temperature and
cardiac cect showed esophageal - mediastinum fistula with encapsulated effusion and pneumatosis behind left atrium ( la ) , and post wall of la depression .
emergency esophagogastroduodenoscopy showed a small and deep ulcer at 30  cm from incisors ( left ) .
right thoracotomy incision through the right 5th intercostal space was made under general anesthesia . during the surgery , we noticed the membranaceous and funicular adhesions between the right lung , diaphragm and mediastinum , white lamellar scars under azygos vein beside left atrial .
after opening mediastinal pleura , tight adhesion between esophagus and pericardium was found and separated carefully , then a 6  mm diameter fistula in the anterior wall of esophagus was discovered ( fig .
tight adhesion between la and pericardium , combined with bleeding at the posterior wall of la , was found during exploratory pericardiotomy .
rid - muscle flap pedicled with vessels was made to repair la posterior wall and fistula between esophagus and la ( fig .
pleuroclysis using povidone iodine and nature saline was performed before sternal closure . a 6  mm diameter fistula ( indicated by blue arrow ) in the anterior wall of esophagus .
rid - muscle flap pedicled with vessels ( indicated by blue arrow ) was used to repair la posterior wall and fistula between esophagus and la .
, the patient was transferred to intensive care unit , and then out - of - control sepsis and infectious shock , which showed repeated fever and chills , metabolic acidosis , hypotension , tachycardia and oliguria , attacked the patient , and caused his death .
aef , a rarely complication of rfca of af , was first reported in 2004 .
some surveys revealed that the incidence was 0.03% to 0.04% in rfca of af and about 1% in iraaf , and its mortality ranging was from 71% to 83%.24 as the number of rfca of af cases grows , more aef cases could be found in recent years .
it was considered that the ablation of the posterior wall of la by the high temperature might be an important risk of aef .
elevated esophageal temperatures during la ablation may occur in more than 50% of patients.5 
 6 
  esophageal stenting and surgical repair are the commonest treatment for aef . to date , we still did not know which one is the best treatment for aef .
fifty - seven relevant articles , including 86 aef patients ( 60 males ) , were analyzed.1 
 661 seventy - eight patients were secondary to rfca of af , and 8 patients were secondary to iraaf .
the incubation period of aef symptoms was from 2 to 60 ( average : 24.8 ) days .
. the symptoms of neurological symptoms , including hemiplegia and epilepsy , consciousness disorder , gi bleeding , chest pain , were relatively common .
the other uncommon symptoms included : nausea and vomiting , dysphagia , dyspnea , cough , arrhythmia , headache , blindness , syncope , abdominal pain , and petechiae ( fig .
chest ct and cect were the most common noninvasive diagnosis methods with high sensitive for aef , which could show the air bubbles or vegetation at the site near the esophagus of la .
transthoracic echocardiography , transesophageal echocardiography , cardiac mri , and contrast esophagram could discover aef ( fig . 7 ) .
abnormal cerebral ct findings , such as cerebral air embolism and multifocal cerebral ischemia , revealed in most of patient on admission .
cect = contrast enhanced computed tomography , ctpa = computed tomography pulmonary angiogram , egd = esophagogastroduodenoscopy , et = exploratory thoracotomy , tee = transesophageal echocardiography , tte = transthoracic echocardiography .
hemorrhage from aef , sepsis , air embolism , and cerebrovascular accidents are the major reasons for a fatal outcome.2 
 6 
 9 
 12 
 23 
 57 esophageal stenting and surgical repair were the major therapies of aef . different therapeutic strategy might influence outcome of patients .
twenty - eight patients without esophageal stenting or surgical repair had higher mortality , only 1 patient who performed endoscopic ligation survived .
but relatively , surgical repair decreased the mortality of the patients significantly , only 12 patients died in 43 patients who only performed surgical .
three patients implanted esophageal stenting after performing emergency atrial wall repair with thoracotomy , 2 patients survived .
two patients , who received esophageal stenting and subsequently performed surgical , were all survived ( table 2 ) .
it is known to all that aef is a life - threatening complication of ablation of af .
according to the literature review of aef , we found that conservative treatment or esophageal stenting alone seemed to be a poor clinical outcomes , and surgical repair combined with or without esophageal stenting may be the preferred option for the patients .
early surgical treatment have lower mortality than delayed strategy.8 
 19 
 23 
 26 
 37 though there were many disputes about the opportunity to put esophageal stent , stenting alone was not recommended for treating aef.26 
 37 the clinical outcomes of combination therapy of esophageal stenting and surgical repair were not clear because of few cases . in our case ,
the patient underwent early esophageal stenting with temporary improvement of the symptoms in the first few days .
but the conditions of the patient were worse , and eventually caused death despite surgical repair was performed .
early resuming oral intake and delayed surgical intervention may be the important factors of relapse .
make a definition diagnosis in time with early primary surgical repair may save their lives .
conservative treatment or esophageal stenting alone may not be a better choice for aef patients .
 abstractintroduction : atrial - esophageal fistula ( aef ) is a rare severe disease , which may be associated with radiofrequency catheter ablation ( rfca ) of atrial fibrillation ( af ) or intraoperative radiofrequency ablation of atrial fibrillation ( iraaf).clinical findings : we reported a case of a 67-year - old man with aef following rfca of af , who treated with esophageal stenting and surgical repair.outcomes:he was attacked by out - of - control sepsis and infectious shock after surgery and died.literature review : we analyzed 57 relevant articles about aef from 2003 to 2015 by searching pubmed database . according literatures , 
 the most common symptoms were fever , rigor , sepsis , and neurologic symptoms . 
 chest computer tomography ( ct ) and contrast enhanced ct may be the reliable noninvasive diagnosis methods because of high sensitive for aef.conclusion:make a definition diagnosis in time with early primary surgical repair may save their lives . 
 conservative treatment or esophageal stenting alone may not be a better choice for aef patients . 
Introduction
Case presentation
Discussion
Conclusion