Atrial esophageal fistula (AEF) is a rare but fatal complication after atrial fibrillation (AFib) ablation. We present 2 cases of AEF complicated by devastating strokes.

Case(1)

A 52 y.o. man developed severe sepsis and seizures 20 days after catheter ablation for AFib. Cerebrospinal fluid (CSF) analysis was unremarkable. MRI brain showed bilateral frontal laminar cortical infarcts. Echocardiography showed no abnormality. Blood cultures were positive for streptococcus mitis and he clinically improved with antibiotics. However, few days later,  he became stuporous with Glasgow Coma Scale 9. Head CT showed hemorrhagic strokes and air emboli. CT chest with contrast showed esophageal perforation and air bubble in the left atrium and superior pulmonary vein. He was deemed a poor candidate for surgery, remained comatose and died 3 weeks after his presentation.

Case(2)

A 42 y.o. man presented with fever and confusion 1 month after left atrial radiofrequency ablation for AFib. Blood cultures were negative, CSF showed leukocytosis and high protein. He was started on antibiotics for meningitis. CT and MRI brain showed multiple foci of cortical strokes and bilateral air emboli. CT chest with contrast showed air posterior to the left atrial wall. Cardiothoracic surgery was scheduled, but the patient had a cardiac arrest beforehand. CTH afterwards demonstrated diffuse cerebral edema and larger air emboli. He was deemed a poor candidate for surgery and was managed medically.  After 53 days he was discharged in a stable condition.

Atrio-esophageal fistula is a serious complication of AFib ablation that causes sepsis and delayed serious neurological sequelae. Multifocal strokes, air emboli, and pneumo-mediastinum are very characteristic findings on imaging. Any esophageal manipulation may cause passage of air and food particles to the systemic circulation. It is unknown if emergent surgical repair improves the survival.