CardioNerds (Amit Goyal) joins Thomas Jefferson cardiology fellows (Jay Kloo, Preya Simlote and Sean Dikdan - host of the Med Lit Review podcast) for some amazing craft beer from Independence Beer Garden in Philadelphia! They discuss a fascinating case of atrioesophageal fistula (AEF) formation after pulmonary vein isolation (PVI). Dr. Daniel Frisch provides the E-CPR and program director Dr. Gregary Marhefka provides a message for applicants. Johns Hopkins internal medicine resident Colin Blumenthal with mentorship from University of Maryland cardiology fellow Karan Desai.
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Episode graphic by Dr. Carine Hamo
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.
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Patient Summary
A man in his mid-60s with a history of paroxysmal Afib presented to the ED after one week of chest pain and altered mental status. His afib had been difficult to rate and rhythm control, and thus he had undergone catheter ablation with pulmonary vein isolation 3 weeks prior to presentation. In the ED he was found to be febrile and had a witnessed seizure. Blood cultures returned positive for Strep agalactiae and his CT head showed multiple areas of intravascular air. Join the Thomas Jefferson University Cardionerds as they take us through an expert discussion on the differential of post-catheter complications, the diagnosis of atrial-esophageal fistula and ultimately management of this potentially fatal complication!
Case Media
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A. ECG: Normal sinus rhythm HR 105 bpmB. CXRC. CT head: Multiple tiny foci of air throughout bilateral cerebral hemispheres. Appearance is most suggestive of intravascular air, although it is unclear if it is venous, arterial or both.D. MRI: 1. Restricted diffusion in bilateral cortical watershed zones, as well as in the posterior medial left cerebellar hemisphere, most consistent with recent infarctions.E. CT Chest: A small focus of air tracking along the left mainstem bronchus anterior to the esophagus, may represent a small amount of pneumomediastinum versus air in an outpouching of the esophagus. No air tracking more cranially along the mediastinal soft tissues. No definite soft tissue defect in the esophagus.F. Surgical repair of LA & Esophagus
Episode Teaching
The CardioNerds 5! – 5 major takeaways from the #CNCR case
What is a pulmonary vein isolation? What are the most common complications? When is catheter ablation indicated?The majority of Afib triggers come from areas where the pulmonary veins attach to the left atrium. Approximately 15-20% of patients undergoing ablation will have non-pulmonary vein triggers. Guided by this anatomic and pathophysiologic underpinning, electrical isolation and ablation of these areas helps prevent propagation of the Afib impulses. The most effective method for pulmonary vein isolation (PVI) is ablation of the PV antrum, areas located near the PV ostia, using an oval mapping catheter to confirm ablation of electrical activity from the PV ostia.Vascular access complications (e.g. hematoma, pseudoaneurysm) are the most common complications following PVI and occur in approximately 1-4% (KD: I think complication rate is lower in studies I've reviewed) cases. Most other complications occur in less than 1% of cases and include cardiac tamponade/perforation, TIA/stroke, PV stenosis, pneumonia, phrenic nerve palsy, gastric motility disorders, atrial-esophageal fistula, and death.There is some growing evidence that catheter ablation may be superior to medical management alone in certain symptomatic populations (e.g., HFrEF). However, in the recent CABANA trial, catheter ablation did not significantly reduce death, disabling stroke, or serious bleeding compared to medical management in all comers with