Iatrogenic Infective Endocarditis With Septic Emboli: An Unusual Complication of Intracardiac Manipulation

Radiofrequency catheter ablation (RFA) is an effective treatment for recurrent symptomatic atrial fibrillation (AF) despite medical therapy. Complications include cardiac tamponade, pulmonary vein stenosis, and rarely atrial-esophageal fistula (AEF). We present a case of a 77-year-old male patient with a history of persistent AF status post posterior left atrial isolation 50 days prior, who presented to the emergency department with bilateral lower extremity weakness ongoing for an hour. In addition, he reported a non-productive cough, chest discomfort, and dysphagia. He was hypertensive, febrile, tachycardic, and with tachypnea on initial assessment. Initial labs revealed leukocytosis with elevated troponin level. Brain imaging confirmed subacute infarcts suggestive of embolic disease. Tissue plasminogen activator was contraindicated. He was admitted for management of altered mental status and sepsis of an unknown origin. Due to associated chest discomfort and dysphagia, computed tomography (CT) scan of the chest with contrast obtained revealed a small focus of air between the posterior wall of the left atrium and the esophagus. A few hours later, he deteriorated with worsened hypoxic respiratory failure, altered mental status, requiring intubation and mechanical ventilation. Cardiothoracic surgery was consulted, and he was taken to the operating room for open-heart surgery due to concern for AEF. Peri-operatively, a left atrial fistula measuring 0.5 cm was identified and closed. Also, a fibrinous material (3 × 4 cm) was identified and removed in the left inferior pulmonary vein. On post-operative day 1, he underwent an upper endoscopy, and a 1 cm esophageal defect was closed. Biopsy from fibrinous material was positive for polymicrobial organisms (lactobacillus, candida, and prevotella), while blood cultures grew Streptococcus anginosus. Despite treatment with aggressive intravenous antibiotics, the patient deteriorated with poor neurological function and ventilator dependency. A multidisciplinary team reached a consensus agreement for palliative measures. To our knowledge, this case represents one of the few cases documenting life-threatening infective endocarditis with septic emboli as a complication of AEF from RFA. Therefore, clinicians should have a high index of suspicion due to associated grave prognosis.