心房颤动导管消融术后疑似心房食管瘘并发冠状动脉空气栓塞：病例报告中血管造影直接显示与导管抽吸

文献信息

中文摘要

背景： 心房食管瘘是心房颤动（AF）导管消融术罕见但致命的并发症。它可表现为感染、吞咽困难或其他吞咽相关症状、神经系统事件和全身性空气栓塞；冠状动脉空气栓塞更为少见。
病例摘要： 一名84岁女性因反复心悸持续1小时入院，约1个月前曾接受心房颤动射频导管消融及左心耳封堵术（RFCA & LAAC）。入院时她为窦性心律，心肌肌钙蛋白水平正常。入院4小时后，她突然无反应，并出现发热和严重呼吸异常。随后心电图显示II、III和aVF导联ST段抬高。急诊冠状动脉造影显示右冠状动脉中段有气体，远端血流TIMI 0级，并进行了导管抽吸。头部和胸部计算机断层扫描（CT）显示多处气体，包括颅内、心腔和大血管。血培养生长星座链球菌及其他链球菌。鉴于近期左心房消融、急性神经和心肌缺血表现、多部位血管内气体，以及口咽或胃肠道菌群相关细菌所致菌血症，高度怀疑心房食管瘘并发全身性空气栓塞。她的病情迅速恶化，出现心脏骤停，并于入院约27小时后死亡。
结论： 对于心房颤动消融后数周内出现发热、意识障碍或急性ST段抬高的患者，应考虑心房食管瘘和冠状动脉空气栓塞。冠状动脉造影可直接显示冠状动脉内气体并进行导管抽吸；然而，心房食管瘘诊断的确定性应与现有影像学证据相符。

英文摘要

UNLABELLED: Atrioesophageal fistula is a rare but fatal complication of catheter ablation for atrial fibrillation(AF). It may present with infection, dysphagia or other swallowing-related symptoms, neurologic events, and systemic air embolism; coronary air embolism is even less common.
CASE SUMMARY: An 84-year-old woman was admitted with recurrent palpitations lasting 1 h, approximately 1 month after radiofrequency catheter ablation for atrial fibrillation and left atrial appendage closure(RFCA & LAAC). On admission, she was in sinus rhythm and had a normal cardiac troponin level. Four hours after admission, she abruptly became unresponsive and developed fever and severe respiratory abnormalities. Electrocardiography subsequently showed ST-segment elevation in leads II, III, and aVF. Emergency coronary angiography demonstrated gas in the mid right coronary artery with TIMI 0 distal flow, and catheter aspiration was performed. Computed tomography (CT) of the head and chest revealed gas at multiple sites, including the intracranial compartment, cardiac chambers, and great vessels. Blood cultures grew Streptococcus constellatus and other streptococci. Given the recent left atrial ablation, acute neurologic and myocardial ischemic manifestations, multisite intravascular gas, and bacteremia with organisms associated with the oropharyngeal or gastrointestinal flora, an atrioesophageal fistula complicated by systemic air embolism was strongly suspected. Her condition deteriorated rapidly, and she developed cardiac arrest and died approximately 27 h after admission.
CONCLUSION: Atrioesophageal fistula and coronary air embolism should be considered in patients who develop fever, impaired consciousness, or acute ST-segment elevation within several weeks of atrial fibrillation ablation. Coronary angiography can directly visualize intracoronary gas and allow catheter aspiration; however, the certainty of an atrioesophageal fistula diagnosis should remain commensurate with the available imaging evidence.