0:00

This is the next case. So this is a gentleman that

0:03

had atrial fibrillation.

0:07

And they were admitted to

0:10

our EP lab for

0:13

RF ablation for their atrial fibrillation.

0:16

And a few weeks later,

0:19

actually, let me rethink that a few.

0:22

Yeah a few weeks later. They represented to our Ed

0:25

to our emergency department with chest pain and

0:28

in the emergency department. We obtain this contrast

0:31

enhanced CT.

0:34

And I'm just going to have you take a look

0:37

at it.

0:40

So again, this is post RF

0:43

ablation for atrial fibrillation.

0:47

This is a contrast enhanced CT. The patient has a

0:50

pacemaker and they come in

0:53

because of chest pain.

0:56

and I'm just gonna

0:58

let this one more time.

1:02

And one last time and then I'm gonna have Ashley bring

1:05

in the pool.

1:09

Okay, so

1:11

Looking at this I'm going to ask you again.

1:14

What is the most likely?

1:17

diagnosis

1:19

is this again a normal study?

1:22

And I said, maybe I'm going to show you normal studies. I mean

1:25

we could talk about normal studies. Is this a

1:28

patient presenting with an acute myocardial infarction?

1:32

Is this an air embolism due to a patent for

1:35

nominal volley?

1:36

Or is this an atrio esophageal fistula?

1:40

Excellent. So again, nobody thinks that

1:43

I'm going to show to normal studies. That's that's so sad.

1:46

So some of you think that this

1:49

patient presents with an acute MI one of

1:52

you guys think that they have an air embolism due to

1:55

a PFO and then the majority thinks

1:58

that there is an age of a geophysula

2:01

and I'm going to walk you through and show you

2:04

what

2:05

features on that CTE you really need

2:08

to pay attention to and why we can come to the correct

2:11

diagnosis, which is actually atrials of a geofestra. So

2:14

kudos to those folks who have checked that

2:17

one. So first of all, how is ablation done

2:20

for atrial fibrillation.

2:24

This is a picture that I stole from YouTube and

2:27

I was hoping to show you the video but I can so this is a depiction of

2:30

the left atrium. And these are the ostea of

2:34

the pulmonary veins. This is the left atrial appendage and

2:37

these very very bright and shiny dotted areas

2:40

are the areas that are going to be zapped

2:43

with this RF ablation tool.

2:47

And these are circles around the pulmonary Venus

2:50

Austria. So there's a circle here. There's a circle here

2:53

and there's theoretically a circle here and a

2:56

circle here.

2:57

now the problem is if you think about it, and you

3:00

just look at the way that

3:03

Your pulmonary arterial Osteo look like so we're

3:06

looking at this area here this area here.

3:10

and

3:13

this area here and ultimately this area here.

3:17

which is a obviously a

3:20

larger area that is being

3:23

rfo bladed and the

3:26

other thing is all of these areas particularly the

3:29

left lower pulmonary vein,

3:32

which is this once a little left inferior pulmonary vein

3:35

comes in right here, and if you look at this structure,

3:39

And we all know what the structure is right up here. It's filled

3:42

with air. This is the esophagus and the

3:45

esophagus is right posterior to

3:48

the left atrium and unfortunately,

3:51

Exactly posterior to the ostium of the

3:54

left inferior Pioneer vein.

3:57

And if you look at this and you follow what

4:00

you're seeing there.

4:04

You have these air lock yours in the

4:07

esophagus then if you look closely you have these airlock

4:10

Hills right here and right here.

4:14

And right here.

4:17

And these are extras of agile air molecules.

4:20

They're not within the esophagus.

4:24

So you have by definition if you have air outside

4:27

of the esophagus if you have air in your posterior mediastinum.

4:31

You know that there has to be a hollow viscous organ

4:34

injury because they're not supposed to have air in your media

4:37

style structures outside of the esophagus.

4:40

And by definition if you have air

4:43

in the esophagus, it's coming from the RF ablation

4:47

because there was no other Interventional done.

4:50

There has to be a hole in the left atrium as well because otherwise

4:53

they couldn't be a hole in the esophagus because everything's

4:56

coming from the inside. So the probe is

4:59

coming in here by a puncture of

5:02

the interatrial septum. They go through the interracial septum.

5:05

And then they ablate around the Osteria of

5:08

the pulmonary veins. So if you have air

5:11

That comes out of the esophagus. It has to be a hole in the

5:14

posterior Atrium as well. Now

5:17

some of you would say well but why isn't there any

5:20

air in the atrium? It's a

5:23

very good question and most of the time the air

5:26

in the atrium that may actually been there or

5:29

may have been there. It's just a tiny molecule

5:32

and because it's a blood-filled structure. It's seals

5:35

with a blood clot yet. You see

5:38

some residual air in the median because they're it persists longer

5:41

and there is no flow.

5:43

but you can also have this which

5:49

I had

5:51

A little bit a while ago. This is a patient who

5:54

also undervent RF ablation of

5:57

and because of pulmonary arterial, sorry because

6:00

of atrial fibrillation and this patient

6:03

and have up having an air fluid

6:06

level structure in

6:09

their left atrium adjacent to

6:12

the osteum of the pulmonary vein. So you see here is

6:15

the Austin of the right inferior pulmonary vein

6:18

and this person actually had their esophagus more to the

6:21

right.

6:23

And they on top of it have a PFO or

6:26

small ASD and you see the wispy thread

6:30

of soft tissue extending into the right atrium

6:33

and attaching and and just,

6:36

you know free floating in the right atrium.

6:39

So this was a true.

6:42

It's of atrials of a geophysula with air

6:45

confined within the right. Hmm. I'm

6:48

totally crazy case going through the interracial

6:51

wall with a thrombin strength that

6:54

is extending into the right atrium. And this person actually went

6:57

to surgery to have this excise as you can imagine. You

7:00

don't want to have an air bubble floating in

7:03

your left atrium because if this would take off it

7:06

would not be it would not be a good thing. So they have

7:09

this excise and then the surgeon close this ASD

7:12

and the patient at fine, but remember if you

7:15

have a patient who comes in

7:18

after RF ablation

7:21

This is what they had done.

7:24

And you really want to scrutinize the mediastinum The

7:28

Atrium and the periods of agile

7:31

structures on your CT. You're not

7:34

looking for large air bubbles. You're not looking for this

7:37

case. You're not looking for the total crazy case here

7:40

with an air fluid level structure in your left atrium.

7:43

You're looking for subtle.

7:45

air molecules

7:48

in

7:49

the vicinity of where they may have ablated and

7:52

particular in the vicinity of the esophagus because that's

7:55

the structure that often gets compromised in

7:58

their bath in their mural integrity

8:01

and you see those earlocules in

8:04

the mediastinum or even as seen in this case in

8:07

the atrium itself now for

8:10

the other cases

8:13

that I put in the the paradoxical

8:16

embolism due to a PFO it's conceivable,

8:19

but it wouldn't stick there.

8:21

And then the other thing obviously

8:24

normal was not and then the third

8:27

the fourth thing that I put in there was

8:30

just an a pulmonary

8:33

arterial a

8:36

pulmonary arterial embolism. That would not end up in the left atrium.

8:40

So again history is key. You need

8:43

to know if someone had this procedure done because then

8:46

you really want to scrutinize the wall of the left atrium. And

8:49

the ostia of the pulmonary veins for potential

8:52

injuries of the surrounding structures and

8:55

the most critical structure that can be injured as

8:58

the esophagus with

8:59

potential devastating outcomes

9:02

are there any questions feel please

9:05

feel free to

9:07

Use the Q&A if there are any

9:10

questions, oh and I should probably say that when

9:13

we assess these we always do

9:17

cardiacated studies.

9:19

if a patient comes after a cardiac intervention

9:22

or cardiac surgery or aortic surgery

9:25

with complications or potential complications

9:28

We obtain cardiacated studies simply because otherwise

9:31

you don't see the structure as well. We would have not seen these little tiny

9:34

airlock Hills.

9:35

If we would have not gotten the

9:38

cardiacated study.

9:40

So just keep that in mind.

9:43

And if you have patients like that.

9:47

And this is just to prove that this actually

9:50

is air.

9:51

I gave you a long Windows here because people could

9:54

also argue. Well, it's maybe fat or something, but you can see

9:57

it's very dark. It's darker than fat and here on the

10:00

long windows. It's actually air.