Treatment of oesophageal perforation with through-the-scope clips post-high-power short-duration atrial fibrillation ablation: case report.

Background: Atrio-oesophageal fistula following percutaneous catheter ablation is a rare but potentially life-threatening complication. This case report highlights the advantages of a less invasive treatment for covered oesophageal perforation.

Case summary: A 66-year-old male patient underwent catheter ablation with high-power short-duration radiofrequency for symptomatic (EHRA III, tachy-cardiomyopathy) persistent atrial fibrillation (AF). Post-procedural routine endoscopic examination revealed a thermal oesophageal lesion. Progression of the lesions in early follow-up examinations led to a CT scan that showed a covered perforation. Antibiotic coverage and parenteral nutrition were initiated. The patient was transferred to a multidisciplinary centre for evaluation of invasive treatments. Endoscopically, the lesions were slowly progressing, while retaining their endoluminal borders. Application of five through-the-scope clips resulted in temporary shielding that was replaced with two further clips 3 days later. This allowed for internal oesophageal healing and prevention of mediastinal infections. Due to recurrence of the AF, a repeat ablation with pulsed field was performed. Follow-up endoscopic examination after one year revealed no relevant lesions. Sinus rhythm and slight odynophagia persisted.

Discussion: This case underlines the importance of less invasive treatments for oesophageal lesions after catheter ablation, where endoluminal borders are preserved and approximation of the wound-margins allows for tissue repair. Although, this kind of treatment requires timely and thorough investigations as endoscopy and CT scan to exclude (peri-)cardiac involvement.