Gas in the Left Atrium and Ventricle

A 60-year-old man with coronary artery disease, ischemic cardiomyopathy with biventricular implantable cardioverter–defibrillator placement, and atrial fibrillation presented with chest pain and numbness in both arms. During his initial presentation, he suddenly collapsed and became unresponsive. Computed tomographic (CT) angiography of his chest, abdomen, and pelvis was performed to evaluate the possibility of aortic dissection. The images showed gas in the left ventricle (Panel A). Further review revealed gas in the left atrium with a connection to the esophagus (Panel B). His family later reported that he had undergone radiofrequency ablation for atrial fibrillation 6 weeks earlier. The gas in the heart was thought to be from an atrial–esophageal fistula that may have developed after this procedure. Imaging also showed renal infarcts, probably from air emboli. Findings from brain imaging were unremarkable, but the patient remained without notable neurologic function. His family elected against surgery, given his poor prognosis. The patient died a few hours after his initial presentation. An atrial–esophageal fistula can be a complication of radiofrequency ablation and is associated with a substantial risk of death. Chest CT is the preferred diagnostic test for this condition; transesophageal echocardiography should be avoided because intubating the esophagus can cause further gas embolization.

一名60岁男性患者罹患冠心病、缺血性心肌病和房颤，并留置双心室植入型心律转复除颤器。患者因胸痛及双臂麻木就诊。到达医院后患者突然晕倒，神志无反应。进行胸腹盆腔CT血管造影以评估主动脉夹层的可能性。影像学检查显示左心室内有气体（图A）。进一步阅片发现左心房内也有气体且与食道相通（图B）。稍后患者家属反映，6周前患者曾接受射频消融治疗房颤。因此，医生认为心脏内气体可能源于上述操作后的心房—食道瘘。影像学检查还显示肾脏梗死（可能由气体栓塞引起）。脑部影像学检查无异常发现，患者仍持续处于严重神经系统障碍的状态。因预后不良，患者家属拒绝手术。数小时后患者死亡。心房—食道瘘是射频消融治疗的一种并发症，显著增加死亡风险。此时，胸部CT是首选诊断方法；应避免进行经食道心脏超声检查，因为可能导致进一步的气体栓塞。