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Covered esophageal stent for failed repair of Left Atrial-Esophageal Fistula
Background
A 72 year-old man with paroxysmal atrial fibrillation who underwent catheter ablation developed a fever and clouded mental state two weeks later. His exam was most consistent with an acute brain injury and a CT scan of the chest was suspicious for air outside the esophagus and within the left inferior pulmonary vein. A diagnosis of left atrial esophageal fistula was made and emergency surgery was performed.
Operative Findings
There were dense adhesion between the esophagus and the right posterior wall of the left atrium (LA). Within the LA there was frank pus with a direct communication into the lumen of the esophagus.
Repair
The left atrium was opened just anterior to the right pulmonary veins. The abscess cavity was entered and debrided. The necrotic endocardium was debrided. The defect in the left atrial wall was patched with pericardium. The esophagus was separated from the pulmonary vein. The mucosa was closed primarily. The muscle layer was closed in two layers and covered with bovine pericardium. Appropriate drains were left in place.
Postoperatively, his condition remained stable but on day 11 he was found unresponsive. CT head showed air in the ventricles. Transthoracic echocardiogram confirmed a new fistula. On exploration he was found to have a new fistula due to
further necrosis, and re-repair was performed with a bovine pericardial patch. A covered esophageal stent was placed.
Outcomes
The patient’s neurological status continued to deteriorate despite stable hemodynamics. A CT scan of the head showed edema, midline shift and significant herniation. Ultimately care was withdrawn.