Teaching NeuroImages: Neurologic deterioration after atrial fibrillation ablation

A 68-year-old man presented with fever and altered mental status 4 weeks following an ablation procedure for atrial fibrillation (AF). Head CT revealed multifocal embolic-appearing infarcts. Chest CT revealed air in the left atrial appendage (figure). These findings led to a diagnosis of cardioembolic stroke secondary to septic emboli from an atrioesophageal fistula (AEF). AEF may occur in up to 0.25% of AF ablations and manifests 1–6 weeks postprocedure with fever, stroke, and/or end-organ damage from septic emboli.1 Transthoracic echocardiogram and chest CT should be considered to rule out AEF in patients with neurologic decline following AF ablation.1,2

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