More attention should be paid to atrial-esophageal fistula, and not all atrial-esophageal fistulas are iatrogenic

We read the article written by Wang et al. in your journal with interest (1). The article introduced the treatment process of an atrial-esophageal fistula (AEF) and reviewed the latest treatment progress. AEF is a rare condition with high mortality, and most AEFs are reported as complications of catheter ablation (1,2). It is a pity that the patient died 24 days after all the medical endeavors. More researches about this devastating disease are necessary to improve its prognosis. As reported in that article and many other cases (1,3), most AEFs were regarded as iatrogenic complications. The fact is that not all AEFs are iatrogenic, and we would like to share our experience with a rarer cause of AEF to extend understanding towards this special disease.

In 2021, a 37-year-old male was transferred to our hospital with intermitted fever for 15 days and left lower limb weakness for 7 hours. His symptom of fever usually occurred at night with the highest temperature ranging from 38.1 to 40.5 ℃. Upon admission, he was barely able to stand on his feet. His vital signs were normal with blood pressure at 133/81 mmHg, heart rate at 90/minute, and respiratory rate at 21/minute. Laboratory tests revealed a high white cell count of 13,170 per cubic millimeter (reference range, 3,500 to 9,500) with neutrophilic percentages at 85.1%. Brain magnetic resonance (MR) showed bilateral infarctions with patchy abnormal intensity on T2-weighted imaging (T2WI) and diffusion-weighted imaging (DWI) (Figure 1A) in both cerebral hemispheres. Chest computed tomography (CT) on the same day to exclude Covid-19 demonstrated a linear high opacity and air bubble at T6/7 level, it extended from the esophagus to the left atrium (Figure 1B,1C), raising the suspicion of an esophagus foreign body and esophagus perforation. Contrast-enhanced CT confirmed the existence of an AEF with pericardial abscess, and multiple intra-cardiac filling defects (red arrow) at the apex of the fish bone and anterior of the left atrium retrospectively were also observed (Figure 1D). Detailed medical history revealed that the patient had eaten fish at dinner 3 days before his symptom occurred, but he denied any symptom of choking, vomiting, or chest pain.

Figure 1 Radiological, intra-operative and pathological findings of the patient. (A) Brain MR of patient revealed multiple lesions with high intensity on diffusion weighted imaging (red arrow). (B,C) Plain CT of the chest showed a linear structure (red arrow) with high opacity between the atrium and the esophagus, which raised suspicion of esophageal foreign body. Air adjacent to the high opacity structure indicated esophageal perforation. (D) Contrast enhanced CT of the chest supported the diagnosis of esophageal perforation and atrioesophageal fistula with two filling defects (possible intra-atrial embolus, red arrow) at the apex of the foreign body and anterior of the left atrium retrospectively. (E) A fish bone with one apex in the left atrium and another side in esophagus was observed (yellow arrow pointed to a picture of the separated fish bone taken during the operation). (F) Necrotic tissue with infiltration of large number of neutrophilic granulocytes [corresponding to (D) red arrow] were observed pathologically (hematoxylin and eosin staining; magnification, ×20).

An exploratory thoracotomy was conducted to remove the foreign body. The surgery confirmed the diagnosis of an esophagus perforation with a fish bone penetrating the left atrium (Figure 1E) and the esophageal wall. Two intra-atrial soft tissue structures were observed during the operation, and they were pathologically diagnosed as necrotic tissue with infiltration of a large number of neutrophilic granulocytes (Figure 1F). The patient’s temperature went down 2 days later after the surgery, and his strength recovered gradually. The patient was discharged from the hospital 14 days later with no feelings of weakness in both limbs. After 6, 12, and 24 months of follow-up, the patient was uneventful.

Our patient was rather fortunate with an uneventful recovery after the surgery considering the high mortality of AEF (4). Radiological examinations including chest CT and brain magnetic resonance imaging (MRI) provided key information in the process of diagnosis (5). And an upper gastroscopy was not performed to avoid worsening the condition (6). Early surgery removed the foreign body successfully, and it might be the most important step for AEFs caused by the esophagus foreign body. Other treatment options existing for iatrogenic AEFs include conservative therapy and esophageal stent, but both of the two methods are unable to remove the foreign body (4).

Finally, we agree with Wang et al.’s opinion (1) that austere challenges exist in the diagnosis and treatment of AEF, and more attention should be paid to AEF. Most AEFs are iatrogenic complications of ablation, and our case indicates that AEFs could be caused by non-iatrogenic reasons such as esophagus fish bone. Urgent surgery might be the first choice to treat AEF no matter if it is iatrogenic or non-iatrogenic.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was a standard submission to Annals of Translational Medicine. The article did not undergo external peer review.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://atm.amegroups.com/article/view/10.21037/atm-23-1275/coif). The authors have no conflicts of interest to declare.

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References

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