Mediastinal Hematoma Associated With Radiofrequency Catheter Ablation of Atrial Fibrillation

A 54-year-old male underwent radiofrequency (RF) catheter ablation for atrial fibrillation with the CARTO® system and a non-contact force-sensing ablation catheter (Thermocool© Surround Flow^TM, Biosense Webster, Inc., CA, USA) under deep sedation. Pulmonary vein isolation (PVI) was performed using computed tomography (CT) merge to avoid RF application near the esophagus (Figure A). Ablation was applied to the left atrial (LA) posterior wall (20–30 W; 20–30 s; no intraesophageal temperature rise ≥40℃). However, 3 months later, he underwent chest CT due to persistent dysphagia, revealing a mediastinal mass (Figure B–D; Supplementary Movie). Endoscopy showed no mucosal lesion, but endoultrasonography (EUS) revealed an extraesophageal mass between the LA and descending aorta (Figure E,F). Fine-needle aspiration indicated a hematoma (Figure G). Anticoagulation (apixaban, CHADS2 0 point) and dual antiplatelet therapy for coronary stenting (performed 2 months after ablation) were reduced to aspirin only. His symptom disappeared 5 months after ablation, and follow-up CT (Figure H) revealed the hematoma had shrunk.

Figure.

Radiofrequency application points merged with CT image (A). Contrast-enhanced CT before the procedure (B), 3 months after (C: arterial phase; D: delayed phase), and 6 months after (H: arterial phase). EUS shows a mediastinal mass between the LA and aorta (E), outside the esophagus (F). FNA revealed fresh hematoma tissue with scattered red blood cells (G, H&E, ×200). CT, computed tomography; EUS, endoultrasonography; FNA, fine-needle aspiration; LA, left atrium.

In contrast to an atrial-esophageal fistula, structural changes in the mediastinum were observed, but not esophageal mucosal changes. Structural changes in the mediastinum have been reported in 27% of patients 1 week after PVI, but they all disappeared after another week,¹ in contrast to the present case that lasted for months. CT or EUS is an important tool for detecting an extraesophageal mass, and electrophysiologists need to be vigilant because mediastinal hematomas can cause dysphagia after PVI.

Disclosures

The authors declare no conflicts of interest.

Supplementary Files

Supplementary Movie

Please find supplementary file(s);

http://dx.doi.org/10.1253/circj.CJ-22-0174

Reference

• 1.   Zellerhoff S, Ullerich H, Lenze F, Meister T, Wasmer K, Mönnig G, et al. Damage to the esophagus after atrial fibrillation ablation: Just the tip of the iceberg? High prevalence of mediastinal changes diagnosed by endosonography. Circ Arrhythm Electrophysiol 2010; 3: 155–159.