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Erschienen in: BMC Cardiovascular Disorders 1/2020

Open Access 01.12.2020 | Case report

Transthoracic echocardiography-monitored CO2-insufflation esophageal endoscopy for diagnosis of Atrioesophageal fistula and prevention of iatrogenic air embolism: a case report

verfasst von: Bing Rong, Xiquan Zhang, Hui Tian, Hongyu Zhang, Ning Zhong, Jingquan Zhong

Erschienen in: BMC Cardiovascular Disorders | Ausgabe 1/2020

Abstract

Background

Atrioesophageal fistula (AEF) is the most fatal complication associated with catheter ablation for atrial fibrillation and cannot be easily detected when thoracic contrast-enhanced computed tomography (CT) is normal.

Case presentation

In this report, we described a diagnostic tool for detecting AEF with doubtful chest CT in which we introduced CO2-insufflation esophageal endoscopy with transthoracic echocardiography monitoring. Using this modified esophageal endoscopy, AEF was established due to the presence of both esophageal lesions and bubbles into the left atrium. That way, our patient accepted to be operated in time with good clinical prognosis.

Conclusions

This modified esophageal endoscopy is an alternative tool for early detection of AEF when normal or doubtful CT findings present.
Hinweise

Supplementary information

Supplementary information accompanies this paper at https://​doi.​org/​10.​1186/​s12872-020-01503-3.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Abkürzungen
AEF
Atrioesophageal fistula
AF
Atrial fibrillation
CT
Computed tomography
CO2
Carbon dioxide
TTE
Transthoracic echocardiography
MRI
Magnetic resonance imaging

Background

Atrioesophageal fistula is a rare but the most fatal complication associated with catheter ablation in atrial fibrillation (AF) (0.03–0.08%) [1]. Chest computed tomography (CT) is recommended for detecting AEF, with a high prevalence of imaging abnormalities (80–90%), while direct imaging abnormalities are seen in just 30–40% [2]. About 10–20% of cases, especially during the early phase of AEF, have no CT abnormalities. Repeat CT may take at least 4 days. Thus, it may result in poor prognosis [2]. An alternative strategy, according to an expert consensus statement, is the use of carbon dioxide (CO2)-insufflation esophageal endoscopy [3]. We report a case using transthoracic echocardiography (TTE) monitoring during CO2-insufflation esophageal endoscopy as a modality for early detection of AEF.

Case presentation

A 57-year-old male patient underwent radiofrequency ablation for persistent atrial fibrillation 40 days prior, and he presented with transient numbness and weakness in his left extremity and new-onset hematemesis and fever (38.9 °C). Laboratory findings showed elevated white blood cell count (13,100/mm3). Brain magnetic resonance imaging (MRI) revealed multiple areas of acute cerebral infarction (Fig. 1). Chest contrast-enhanced CT showed a suspected hypodensity region in the posterior aspect of the left atrium (Supplementary figure S1). TTE excluded any heart valve disease, left ventricle contractility impairment and intracardiac thrombus or vegetation. AEF was suspected due to his presenting symptoms and MRI findings. While CT scan didn’t present the obvious abnormality, to confirm this suspicion, CO2 insufflation was administered during esophageal endoscopy. TTE was constantly used to monitor intracardiac bubbles to avoid an iatrogenic air embolism due to uncontrolled introduction of CO2 into left atrium. During the proposed procedure, if bubbles were visualized on TTE, the examination would be stopped immediately and the remaining gas would be pumped out. At 32 cm from the incisors, a 5-mm fistula with active bleeding was seen on the anterior esophageal wall (Fig. 2a). At the end of the examination, bubbles were suddenly seen in the left atrium, with no change in the electrocardiogram and no occurrence of cardiac or neurological symptoms. Thus, AEF was confirmed 3 h after admission. Emergency surgery was performed. During surgery, a 10-mm atrial defect near the left inferior pulmonary vein was repaired using a bovine pericardial patch (Fig. 2b). A 5-mm perforation on the anterior esophageal wall was directly sewn. On postoperative day 7, a cine esophagogram with oral contrast showed no leakage. On postoperative day 30, the proposed esophageal endoscopy found the fistula healing, and the patient was discharged with a normal diet, complete neurologic recovery, and no AF episodes.

Discussion & Conclusion

A case of cardiac ischemia and the necessity for cardiopulmonary resuscitation during CO2-insufflation esophageal endoscopy was reported before. This indicates the potential risk of an iatrogenic air embolism when CO2 is uncontrollably introduced [4]. We suggested a modified CO2-insufflation esophageal endoscopy technique using TTE monitoring to safely and directly diagnose AEF early. We propose it as an alternative modality when chest CT is normal. It is reported that a 5-mL intracoronary CO2 injection had a profound influence on left ventricular function in swine [5]. Therefore, during CO2-insufflation esophageal endoscopy, the CO2 amount administered must be carefully controlled. Contrast-enhanced TTE is a safe and widely used method to detect patent foramen ovale because of high sensitivity of TTE to air signal. The contrast agent is a mixture of 9-mL saline and 1-mL air [6]. That means that few amount of microembolic air is safe. The modified modality employed in the present case promises of lower risk of iatrogenic air embolism as few CO2 is introduced into systemic circulation thanks to simultaneous TTE monitoring and pumping out of the remaining CO2. Therefore with this modality, AEF can be early diagnosed if esophageal lesions are uncovered or bubbles appear in the left heart. Due to lack of publication and series of cases, the reliability of this method needs further investigation.
In conclusion, this TTE-monitored CO2-insufflation esophageal endoscopy is an alternative modality for early confirmation of AEF when there is a high level of suspicion and a normal chest CT result.

Supplementary information

Supplementary information accompanies this paper at https://​doi.​org/​10.​1186/​s12872-020-01503-3.

Acknowledgements

Not Applicable.
The index patient has given a written consent of anonymous use of the clinical data for academic use, research purposes and publications. The case had been approved by the Ethics Committee of Qilu Hospital of Shandong University.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images.

Competing interests

There is no conflict interest to be declared.
Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://​creativecommons.​org/​licenses/​by/​4.​0/​. The Creative Commons Public Domain Dedication waiver (http://​creativecommons.​org/​publicdomain/​zero/​1.​0/​) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Metadaten
Titel
Transthoracic echocardiography-monitored CO2-insufflation esophageal endoscopy for diagnosis of Atrioesophageal fistula and prevention of iatrogenic air embolism: a case report
verfasst von
Bing Rong
Xiquan Zhang
Hui Tian
Hongyu Zhang
Ning Zhong
Jingquan Zhong
Publikationsdatum
01.12.2020
Verlag
BioMed Central
Erschienen in
BMC Cardiovascular Disorders / Ausgabe 1/2020
Elektronische ISSN: 1471-2261
DOI
https://doi.org/10.1186/s12872-020-01503-3

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