Percutaneous catheter radiofrequency ablation (RFA) is an effective treatment for atrial fibrillation. A rare but severe complication is atrioesophageal fistula formation. Early recognition is essential, as delayed diagnosis often leads to death. A 56-year-old woman underwent RFA for atrial fibrillation. The procedure was initially uncomplicated. On day 41 post-procedure, she suddenly developed neurological deficits, including weakness and confusion. She was admitted in a critical state, unconscious and in coma. Imaging studies revealed cerebral ischemia on MRI and cerebral air embolism on CT scan. Further CT imaging confirmed a fistulous connection between the posterior wall of the left atrium and the esophagus. Despite urgent supportive measures—including ventilatory support, broad-spectrum antibiotics, and renal replacement therapy—her condition worsened. She developed signs of sepsis, multi-organ failure, and hemodynamic instability. Due to her unstable condition, surgical intervention was not performed, and despite intensive supportive measures, this case resulted in a fatal outcome.

This case highlights that atrioesophageal fistula can develop several weeks after atrial ablation, with symptoms often appearing around 4–6 weeks post-procedure. Early recognition of this rare complication is crucial for prompt management. While surgical intervention remains the definitive treatment, conservative management may be considered in cases where surgery is not feasible. Increasing awareness of this complication and careful post-procedural monitoring are essential to improving patient outcomes.