[Neurological complications of atrioesophageal fistulas: postprandial insults, epilepsy and meningitis].

BACKGROUND: Atrioesophageal fistulas (AEF) are a life-threatening complication of left atrial ablation for atrial fibrillation or other atrial rhythm disorders, which mostly manifest as neurological deficits. AEFs result in an overflow of esophageal contents into the left atrium with subsequent systemic embolization.
RESULTS: AEFs have been reported in 40 patients, including 18 males, between 35 and 72 years of age. AEFs manifested clinically between 3 and 36 days following the ablation. The most common neurological manifestations are postprandial embolic stroke followed by epileptic seizures and meningitis. More rarely, disorders of consciousness without epilepsy or stroke, psychiatric abnormalities or cerebral air embolisms have been observed. The diagnosis is made upon thoracic computed tomography with contrast medium. Deglutation radiography, transesophageal echocardiography, gastroscopy and esophageal stenting must be absolutely avoided. The only expedient therapy is surgical cleansing of the fistula but even then the prognosis is very poor with a mortality of 63%.
CONCLUSIONS: An AEF should always be considered in patients with fever, difficulties in swallowing, thoracic pain, postprandial transient ischemic attacks (TIA) or stroke, epileptic seizures, or meningitis. In the case of AEFs an ablation of atrial fibrillation in the patient history should be considered and corresponding diagnostics and treatment should be initiated immediately.