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A Catch 22: Ablate the Heart, Perforate the Esophagus
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A5172 - A Catch 22: Ablate the Heart, Perforate the Esophagus
Author Block: S. Zaki1, S. Patel2; 1Internal Medicine Residency Program, Florida State University/Tallahassee Memorial Hospital, Tallahassee, FL, United States, 2Internal Medicine Residency, The Florida State University College of Medicine at Tallahassee Memorial Healthcare, Tallahassee, FL, United States.
The Florida State University College of Medicine Internal Medicine Residency Program.
Introduction
Esophageal perforation is a rare but life threatening complication. While the most frequent etiology is iatrogenic (2%), less likely causes include traumatic, spontaneous, and malignant. Common iatrogenic causes include endoscopy, nasogastric tube placement, intubation, and thyroidectomy while a rare cause includes transesophageal echocardiogram (0.02%). We present a case of a transesophageal echocardiogram for radiofrequency ablation of atrial flutter complicated with cervical esophageal tear resulting in further hospitalization days.
Case Presentation
A 51-year-old male with significant medical history of sick sinus syndrome status post pacemaker anticoagulated on Rivaroxaban, coronary artery disease with percutaneous coronary intervention and cerebrovascular accident presented to a tertiary medical center after being evaluated at an outside medical facility for two days of neck pain postoperatively after an elective outpatient transesophageal echocardiogram and radiofrequency ablation procedure for persistent atrial flutter. His left anterolateral neck pain continued to progress with odynophagia to solids then to liquids. Vital signs were unremarkable. Physical examination was significant for palpable crepitus on anterolateral neck to left face. Diagnostic imaging with CT scan of neck showed a cervical esophageal tear, subcutaneous emphysema, pneumomediastinum and retropharyngeal abscess. He was immediately started on empiric broad spectrum antibiotics, kept on a nothing-by-mouth diet and transferred to the intensive care unit for monitoring. Our cardiothoracic team indicated that no surgical intervention would be needed and unfortunately patient remained hospitalized for an additional three days prior to being discharged. Upon follow up, his symptoms resolved and subcutaneous emphysema improved.
Conclusion
Transesophageal echocardiogram and ablational procedures remains the cornerstone of management for atrial fibrillation and atrial flutter, however these procedures are still associated with risks which are rare but can be fatal. As with every intervention, the risks versus benefit must be weighed. This case highlights the overuse of a common elective procedure which may have been prevented with transthoracic echocardiography.
Sdralis, E., Petousis, S., Rashid, F., Lorenzi, B. and Charalabopoulos, A. (2017). Epidemiology, diagnosis, and management of esophageal perforations: systematic review. Diseases of the Esophagus, 30(8), pp.1-6.
Brinster CJ, e. (2017). Evolving options in the management of esophageal perforation. - PubMed - NCBI. [online] Ncbi.nlm.nih.gov. Available at: https://www.ncbi.nlm.nih.gov/pubmed/?term=15063302 [Accessed 4 Aug. 2017].
Richardson, J. (2005). Management of esophageal perforations: the value of aggressive surgical treatment. The American Journal of Surgery, 190(2), pp.161-165.
Author Block: S. Zaki1, S. Patel2; 1Internal Medicine Residency Program, Florida State University/Tallahassee Memorial Hospital, Tallahassee, FL, United States, 2Internal Medicine Residency, The Florida State University College of Medicine at Tallahassee Memorial Healthcare, Tallahassee, FL, United States.
The Florida State University College of Medicine Internal Medicine Residency Program.
Introduction
Esophageal perforation is a rare but life threatening complication. While the most frequent etiology is iatrogenic (2%), less likely causes include traumatic, spontaneous, and malignant. Common iatrogenic causes include endoscopy, nasogastric tube placement, intubation, and thyroidectomy while a rare cause includes transesophageal echocardiogram (0.02%). We present a case of a transesophageal echocardiogram for radiofrequency ablation of atrial flutter complicated with cervical esophageal tear resulting in further hospitalization days.
Case Presentation
A 51-year-old male with significant medical history of sick sinus syndrome status post pacemaker anticoagulated on Rivaroxaban, coronary artery disease with percutaneous coronary intervention and cerebrovascular accident presented to a tertiary medical center after being evaluated at an outside medical facility for two days of neck pain postoperatively after an elective outpatient transesophageal echocardiogram and radiofrequency ablation procedure for persistent atrial flutter. His left anterolateral neck pain continued to progress with odynophagia to solids then to liquids. Vital signs were unremarkable. Physical examination was significant for palpable crepitus on anterolateral neck to left face. Diagnostic imaging with CT scan of neck showed a cervical esophageal tear, subcutaneous emphysema, pneumomediastinum and retropharyngeal abscess. He was immediately started on empiric broad spectrum antibiotics, kept on a nothing-by-mouth diet and transferred to the intensive care unit for monitoring. Our cardiothoracic team indicated that no surgical intervention would be needed and unfortunately patient remained hospitalized for an additional three days prior to being discharged. Upon follow up, his symptoms resolved and subcutaneous emphysema improved.
Conclusion
Transesophageal echocardiogram and ablational procedures remains the cornerstone of management for atrial fibrillation and atrial flutter, however these procedures are still associated with risks which are rare but can be fatal. As with every intervention, the risks versus benefit must be weighed. This case highlights the overuse of a common elective procedure which may have been prevented with transthoracic echocardiography.
Sdralis, E., Petousis, S., Rashid, F., Lorenzi, B. and Charalabopoulos, A. (2017). Epidemiology, diagnosis, and management of esophageal perforations: systematic review. Diseases of the Esophagus, 30(8), pp.1-6.
Brinster CJ, e. (2017). Evolving options in the management of esophageal perforation. - PubMed - NCBI. [online] Ncbi.nlm.nih.gov. Available at: https://www.ncbi.nlm.nih.gov/pubmed/?term=15063302 [Accessed 4 Aug. 2017].
Richardson, J. (2005). Management of esophageal perforations: the value of aggressive surgical treatment. The American Journal of Surgery, 190(2), pp.161-165.
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