One-step thoracotomy approach for atrial-esophageal fistula repair without cardiopulmonary bypass

A 61 year-old man presented to the emergency department with a history of 3 days of fever. He had a history of radiofrequency catheter ablation of AF 1 month prior to admission, end-stage renal disease requiring hemodialysis, and pacemaker insertion. After admission to the hospital for evaluating the cause of fever, altered mental status was noted. Brain magnetic resonance imaging (MRI) showed a multifocal embolic infarction. Streptococcus salivarrius and Streptococcus mitis/oralis were found in blood culture. Chest computed tomography (CT) demonstrated AEF (Fig. 1a).

A surgical strategy was urgently planned. After endotracheal general anesthesia, the patient was placed in the right lateral decubitus position. Single-lung ventilation was initiated. A thoracotomy was performed on the left 5th intercostal space. After left lung retraction, the pericardium was opened, revealing severe adhesions. Accessing the fistula through the pericardial space was attempted but was abandoned due to excessive adhesions. Attention was then turned to the outside of the pericardium. After retracting the left lung forward, we accessed below the left main bronchus and confirmed the left superior and inferior pulmonary veins. Then we approached behind the pulmonary veins and performed dissection. After opening the mediastinal pleura on the left hilum, the esophagus behind the pericardium was identified. Efforts were made to avoid any vascular damage because it is located more medially than the descending aorta. Between the esophagus and the posterior pericardial wall, the fistula site was observed (Fig. 2). We confirmed the 3 mm fistula with esophageal traction cautiously. Since there were no CT findings or surgical evidence suggesting an abscess, we judged that the situation was not severe in terms of localized infection. From posterior pericardial reflection, three pledgeted 4–0 prolene sutures were gently placed on the fistula on the pericardial side. Fistula ligation and resection were followed by an additional primary repair of the esophageal defect. The mucosal defect was repaired with interrupted 4–0 vicryl sutures, and the muscularis was reapproximated with interrupted 3–0 silk sutures. The repair procedure was finished after considerable irrigation of the chest and a chest tube was inserted.

Postoperatively, the patient was treated for sequelae from the initial stroke and pneumonia. After 1 week without oral nutrition, we confirmed a well-repaired fistula site without residual lesions on endoscopy (Fig. 1b). The patient was discharged on postoperative day 31 with a tracheal tube.

A 70 year-old man underwent radiofrequency catheter ablation for AF. Fifty days following the procedure, he was admitted for cognitive decline. Multiple cerebral infarct lesions were observed on brain MRI. Blood cultures were taken to determine the cause of the patient’s fever. Multiple Streptococcus spp. were confirmed. A CT scan of the chest was suggestive of an AEF (Fig. 1c).

Surgery was urgently performed. The surgical approach was the same as in patient 1. After left thoracotomy on the 5th intercostal space, inspection of the pericardial space showed calcified adhesions. Through the posterior mediastinal space, the esophagus was exposed and pulled gently. The 3 mm fistula on the posterior aspect of the pericardium was isolated and carefully ligated with several pledgeted 4–0 prolene sutures. After fistulectomy, primary esophageal repair was performed in the same manner as the first case. After irrigation, a chest tube was then inserted. The wound was closed in a layered fashion.

The patient's postoperative program was focused on respiratory care with tracheostomy and rehabilitation for the cerebral infarction sequelae. Endoscopic findings were nonspecific after 1 week of fasting (Fig. 1d). The patient was discharged on postoperative day 23 with a tracheal tube.