Aorto-atrial Fistula Research Articles

Abstract 19189: A Rare Case of Neisseria Gonorrhoeae Native Aortic Valve Infective Endocarditis With Development of Gerbode Defect

Introduction: Infective endocarditis (IE) is a devastating condition most commonly caused by gram-positive cocci ( S. aureus , S. viridans , S. gallolyticus , Enterococcus spp.) and gram-negative organisms (e.g. HACEK organisms). We present a case of Native Aortic Valve IE due to disseminated N. Gonorrhea in an immunocompetent patient. Hospital Course: The patient is a 30-year-old female who presented with a chief complaint of subacute chest pain and constitutional symptoms. Echocardiography revealed aortic valve abscess and severe aortic insufficiency with concerns of aorto-atrial fistula. The patient was treated with antibiotics and transferred to our hospital. Upon transfer, the patient was initially stable. Physical exam was notable for a pandiastolic murmur. The patient rapidly deteriorated into cardiogenic and septic shock. TTE revealed aortic root abscess, LVOT-RA fistula (Gerbode defect), and right atrial vegetation. Emergent surgical exploration revealed IE of the aortic valve with destruction of right and non-coronary cusps and vegetation eroding from the base of the aortic root through the membranous septum to the right atrium without tricuspid valve involvement. She underwent successful treatment with debridement and reconstruction. Initial blood cultures were positive for N. gonorrhoeae. The patient was negative for HIV and no gynecologic source was identified. After an extended hospital course, the patient was discharged with IV antibiotics. Discussion & Conclusion: We present a rare case of N. Gonorrhoeae aortic valve endocarditis leading to aortic valve destruction with subsequent abscess and fistulae formation. This case demonstrates a rare and severe consequence of disseminated gonococcal infections (DGI), though the patient was without other manifestations of DGI.

Abstract 14581: Massive Sinus of Valsalva Aneurysm With Rupture Into the Right Atrium

Case Presentation: A 40-year-old male presented with decompensated heart failure and severe pulmonary hypertension (echo-predicted right ventricular systolic pressure 60 mmHg). Right heart catheterization revealed high output heart failure (cardiac index 7.3 L/min/m 2 ), left to right shunt (Qp:Qs 3.6:1), pulmonary hypertension (mean 38 mmHg), and normal pulmonary resistance (1.53 Wood units). Transesophageal echocardiogram revealed a large non-coronary sinus of Valsalva aneurysm with communication to the right atrium (Figure 1a and b). Percutaneous transcatheter closure of the aneurysm was deferred due to large size (3.3 x 4.3 cm), proximity to the right coronary artery, and risk of aneurysm rupture with catheter manipulation (Figure 1c). The patient underwent surgical aneurysm resection and aortic root replacement and recovered well. Discussion: Sinus of Valsalva aneurysms (SVAs) are rare pathologies characterized by expansion of the aortic root wall between the sinotubular junction and the aortic valve annulus and are often associated with connective tissue disorders. SVAs are often diagnosed incidentally on imaging but can present with symptoms if they rupture into nearby cardiac structures, such as an aorto-atrial fistula with left to right shunting, high output heart failure and hemodynamic compromise, as in this case. While transthoracic echocardiogram is the diagnostic modality of choice for most SVAs, multimodality imaging, catheterization, and advanced imaging may also be needed. Surgical repair remains the gold standard of therapy, however treatment with transcatheter device placement has also been successfully performed.

Asymptomatic Aorto-Atrial Fistula Secondary to Surgical Repair of Ascending Aortic Dissection: When to Do Nothing

Secondary aorto-atrial fistula is a rare but potentially life-threatening complication of ascending aortic dissection surgical repair. Secondary aorto-atrial fistulas commonly lead to symptomatic heart failure requiring emergent repair. We present a rare case of secondary aorto-atrial fistula after surgical repair of aortic dissection that remained asymptomatic for a decade. (Level of Difficulty: Intermediate.)

P176 MITRAL FISTULA IN PATIENT WITH OUTCOMES OF TRANSCATHETER AORTIC VALVE IMPLANTATION: A CASE REPORT

Abstract Infective endocarditis (IE) following transcatheter aortic valve replacement (TAVR) has been associated with a poor prognosis. The development of an aorto–atrial fistula (AAF) is a rare but problematic complication of IE, which can be confirmed with transesophageal echocardiography. A 55–year–old man, asthmatic and allergic (Penicillin and ASA) went to the emergency room for therapy–resistant hyperpyrexia and was admitted to Medicine Department for the necessary investigations and treatment. In remote pathological history: ischemic heart disease with dilated–hypokinetic evolution, already revascularized by CABG in 1996 and by PTCA in 2006 and in 2016; transcatheter aortic valve replacement with biological prosthesis in 2018. In the next medical history: admission to neurosurgery about 9 months before for cerebral haemorrhage and implantation of CRT– ICD about 6 months before On the echocardiogram performed at the entrance, evidence of isoechoic formation on the mitral flap for which further study with TEE was recommended. Blood cultures performed during hospitalization were positive for S. Epidermidis Oxacillin resistant. Few days after the admission, due to a sudden worsening of the respiratory picture, the patient was subjected to oro–tracheal intubation and transferred to Intensive Care Unit. The transesophageal echocardiogram (figure) performed in urgency documented: “fistula on the anterior flap of the mitral with medium–severe flow directed from the outflow tract of the left ventricle to the posterolateral wall of the left atrium.” On the recommendation of the infectious disease consultant, intravenous antibiotic therapy with Vancomycin and Gentamicin was started. In the following days, there was a progressive improvement in hemodynamics and the respiratory picture, for which the patient was transferred to Cardiac Surgery to undergo mitral valve replacement surgery. In literature, patients with perivalvular extension of infective endocarditis show very high early and late mortality rates, and surgery during hospitalization for IE appeared to be associated with better outcomes.

Acquired Aorto-Atrial Fistula from Intravenous Drug Use with Underlying Congenital Heart Disease.

The development of an aorta-atrial fistula secondary to mechanical aortic valve infective endocarditis, is a rare, serious complication. The fistula is an aberrant intra-cardiac shunt that occurs between the aorta and either the left or right atrium.

Endovascular repair of ascending aortic diseases with custom-made endografts.

The aim of this article is to report the mid-term results of ascending thoracic endovascular aortic repair using a custom-made device (CMD). This was a retrospective study performed at tertiary centres. Nine patients considered unfit for open surgery received elective total endovascular repair of the ascending aorta with a Relay® (Terumo Aortic, Sunrise; FL, USA) CMD: pseudoaneurysn (n = 5), localized dissection (n =3) and contained rupture (n = 1). Primary clinical success was achieved in all patients with no major complications and no early conversion to open surgery. All patients were discharged home and independent: median length of stay was 7 days (interquartile range, 6-18). No patient was lost to follow-up at a median 26 months (interquartile range, 12-36). Three patients died 2, 6 and 24 months after intervention; 1 was aorta related (late aorto-atrial fistula due to infection that required open surgery). At the last follow-up available, no endoleaks, migrations, fractures or ruptures were observed in the remaining 6 patients. Ascending thoracic endovascular aortic repair with Terumo Aortic CMDs was technically feasible, effective and safe in very selected lesions. CMDs showed good ascending aorta conformability with different configurations and diameters, and satisfactory mid-term durability as shown by both structural integrity and aortic lesion exclusion.

Ruptured sinus of Valsalva aneurysm: diagnosis by community echocardiography

SummaryA 71-year-old man was referred to a general practitioner with specialist interest (GPSI) in cardiology due to exertional breathlessness. Examination revealed a continuous murmur but no signs of heart failure. Echocardiography revealed significant aortic root enlargement (63 mm) with aneurysmal dilatation of the right sinus of Valsalva (Fig. 1A, Video 1) and severe aortic regurgitation (Fig. 1B). Parasternal short-axis images suggested rupture of the aneurysmal right aortic sinus (Fig. 1C, Video 2) with colour Doppler imaging suggestive of a shunt from the aorta into the right atrium (Fig. 1D, Video 3). The study was uploaded to a cloud-based server (Ultralinq Healthcare Solution Inc, New York, USA) and the GPSI contacted the local tertiary centre urgently. On image review, the suspicion was confirmed of an aorto-atrial fistula secondary to the ruptured sinus of Valsalva aneurysm and the patient was hospitalized the same day. At surgery, the aortic root had significantly thinned walls in all sinuses with the presence of a large aneurysm extending from the right coronary sinus towards the right ventricular outflow tract. The fistulous communication was identified and led into the right atrium — this was repaired with pledgeted sutures. A modified Bentall procedure was performed, with a 27 mm Perimount, bioprosthesis sewn into a 34 mm Valsalva Gelweave graft for the aortic root replacement. Sinus of Valsalva aneurysm is a rare abnormality (population incidence 0.09%) that occurs due to a weakening of the layers of the aortic wall (principally the aortic media). This may be due to a congenital abnormality in the aortic wall or may be acquired following bacterial endocarditis or connective tissue disorders. Most aneurysms arise from the right coronary sinus and at least 1/3 will rupture. Rupture into the right heart chambers can lead to a significant intra-cardiac shunt and acute heart failure. In recent years, there has been a significant expansion of community cardiology clinics, including the provision of echocardiography. The method of storage of echocardiographic studies is variable — this case highlights not just the potential value of skilled community echocardiography operators but also the value of cloudbased servers that can facilitate rapid expert review of images performed remotely so that timely management decisions can be made.

P1716 Aorto-left atrial fistula with left atrium dissection

Abstract We report a 71 year-old female with a history of rheumatic valvulopathy, who underwent St. Jude 23 and St. Jude 21 in mitral and aortic position replacement. The patient was admitted to the ER for pulmonary edema with haemoglobin level of 7.7 g/dL .No evidence of gastrointestinal bleeding. She was assessed to exclude intravascular hemolysis: bilirrubin 3.1mg/d,L direct bilirrubin 1.0 mg/dL, reticulocytes 207.000/mcL 6.8%, LDH 1.213, free plasmatic haemoglobin 9.6mg/dL, haptoglobin < 1 mg/dL, negative direct and indirect Coombs. Upon suspicion of hemolytic anemia in relation to prosthetic dysfunction, TEE was performed revealing stenotic mechanical aortic prosthesis with abundant pannus and normofunctional mitral prosthesis, no leakages were observed. A coronary CT scan showed severe calcification of the aortic root and mitral annulus without evidence of redundant tissue than hindered the opening of the aortic or mitral valves. Cardiac catheterization revealed normal coronary arteries, cardiac output preserved and mild passive predominance of PAP. Heart Team decided on aortic prosthesis valve replacement. On March 22, 2019 surgery was performed. There was a heavily calcified ascending aorta and aortic root with abundant pannus at the ventricular aspect of the aortic prosthesis. Former aortic prosthesis was resected and the root reconstructed with a pericardial patch. 18-mmATS mechanical aortic prosthesis was implanted. After 127minutes of cross-clamping time, the patient was admitted to the ICU. She presented a torpid course in the postoperative period after cardiac surgery and cardiogenic shock ensued. TEE was repeated, showing pseudoaneurysm of the mitral–aortic intervalvular fibrosa, left atrium dissection and severe paraprosthetic aortic leakage. Coronary CT scan revealed a large cavity, 7x4x3.5 cm, extending posteriorly and displacing cranially the right pulmonary artery and subsequently rejecting the cavity of left atrium; with final diagnosis of aorto-left atrial fistula with left atrium dissection. Emergent surgery was decided. During the procedure, mitral–aortic intervalvular fibrosa pseudoaneurysm was confirmed, perforation from the subaortic left ventricle into the left atrium was also appreciated at the junction of the aortic root pericardial patch with the dissected left atrium wall. Surgery was complicated with hemorrhagic shock and massive uncontrolled bleeding with severe coagulopathy and thrombocytopenia. The patient went into cardiac arrest and passed away in the operating room. Conclusion Aorto atrial fistulas are rare but important complications of many disease processes of the aorta and aortic valve. Classical clinical signs of continuous murmurs may not be present and echocardiography forms the cornerstone of diagnosis. AAF should be suspected in patients with poorly controlled heart failure and prior aortic surgery. Prompt surgical repair is usually helpful in relieving symptoms and decreasing mortality. Abstract P1716 Figure. Aortoatrial fistula

Aorto-atrial fistula formation and closure: a systematic review.

Blood flow between the aorta and atrium is a rare but complex pathological condition, also known as aorto-atrial fistula (AAF). The exact incidence of this condition is unknown, as are the major precipitating factors and best treatment options. We carried out a systematic review of the available case report literature reporting AAF. We systematically reviewed literature on AAF formation and closure. Separate Medline (PubMed), EMBASE, and Cochrane database queries were performed. The following MESH headings were used: atrium, ventricle, fistula, cardiac, shunts, aortic, aorto-atrial tunnels and coronary cameral fistula. All papers were considered for analysis irrespective of their quality, or the journal in which they were published. Fistula formation from the ascending aorta to the atria occurred more often in the right atrium compared to the left. Endocarditis was the major cause of AAF formation, whilst congenital causes were responsible for nearly 12%. In a number of cases fistula formation occurred secondary to cardiac surgery, whilst chest traumas were a relatively rare cause of AAF. Correction via an open surgical approach occurred in 73.5% of cases, whilst percutaneous intervention was utilised in 10% of patients. In 74.3% of all studied cases the fistula repair was successful and patients survived the procedures. In 14.7% of the cases patients did not survive. Similar outcomes were observed between percutaneous and surgical interventions. Data from larger populations with AAF is lacking, meaning that specific data regarding incidence and prevalence does currently not exist.

Aorto-atrial fistula formation and therapy.

Aorta-atrial fistulas (AAF) are a rare but complex pathological condition. These fistulas are characterised by aberrant blood flow between the aorta and either atrium. In the present manuscript, we present a comprehensive overview of the clinical characteristics, formation and treatment of this condition. A literature review was conducted using PubMed. Aorta-Atrial Fistula was used as the primary search term. The clinical presentation of AAF encompasses a wide range of signs and symptoms of heart failure including dyspnoea, chest pain, palpitations, fatigue, weakness coughing or oedema. Causes of fistulas can be congenital or acquired, whilst diagnosis is normally achieved via echocardiography or MRI. Due to the low incidence of AAF, no clinical trials have been performed in AAF patients and treatment strategies are based on expert opinion and consensus amongst the treating physicians. Uncorrected AAF may continue to impose a risk of progression to overt heart failure. The repair of an AAF can either be surgical or percutaneous. AAF is a relatively rare but very serious condition. Clinicians should consider the possibility of AAF, when a new continuous cardiac murmur occurs, especially in patients with a history of cardiac surgery or with signs of heart failure. Closure of the AAF fistula tract is generally recommended. Further studies are required to define optimal therapeutic strategies, but these are hindered by the rarity of the occurrence of this disorder.

Aorto-Right Atrial Fistula After Bentall Repair

We describe a man with the Marfan syndrome and a prior ascending aortic aneurysm resection who presented with knee pain and concern of endocarditis. Transesophageal echocardiogram showed no vegetations, and computed tomography angiogram of the heart showed a possible pseudoaneurysm. Cardiac catheterization and aortogram revealed the diagnosis of an aorto-right atrial fistula, which was then operatively repaired. This case highlights the role that cardiac catheterization with aortogram can play in the detection of aorto-atrial fistula.

Transcatheter closure of an aortoatrial fistula following a surgical aortic valve replacement

Aorto-atrial fistulas are rare complications of aortic valve replacement. We report a case of a post-aortic valve replacement aorto-atrial fistula that was closed percutaneously with an Amplatz Ductal Occluder-II device.

Simultaneous Percutaneous Closure of Paravalvular Aortic Leak and Aorto-Atrial Fistula Guided by Two-Dimensional Transesophageal Echocardiography

Simultaneous Percutaneous Closure of Paravalvular Aortic Leak and Aorto-Atrial Fistula Guided by Two-Dimensional Transesophageal Echocardiography

Simultaneous Percutaneous Closure of Paravalvular Aortic Leak and Aorto-Atrial Fistula Guided by Two-Dimensional Transesophageal Echocardiography

Simultaneous Percutaneous Closure of Paravalvular Aortic Leak and Aorto-Atrial Fistula Guided by Two-Dimensional Transesophageal Echocardiography

EComment. Aorto-right atrial fistula in type A aortic dissection

I read with great interest the paper by Pagni et al. concerning the management of a 69-year old female patient with acute type A aortic dissection complicated by a fistula to the right atrium [1]. This article has two interesting features that could be of use to all of us when faced with a similar case. The optimal surgical approach to patients who present with acute type A aortic dissection in the setting of previous cardiac surgery is not always apparent. Adhesions from previous cardiac surgery have been proposed to prevent free rupture of the ascending aorta, this lowered risk of rupture and tamponade has led some to suggest delaying the operation with the intention of obtaining cardiac catheterization, especially in the setting of prior coronary artery bypass grafting surgery. Although extensive adhesions might protect against free rupture, there is another risk — fistulization or contained rupture of the aorta into neighbouring cardiac chambers and pulmonary artery. In this case scenario, surgical intervention is emergently required to prevent dismal prognosis secondary to preoperative cardiogenic shock. In a recently published study, Klodell et al. [2] showed that patients with acute type A aortic dissection with a history of cardiac surgery are at increased risk for aortic rupture when compared to aortic dissection without previous cardiac surgery (29 % vs 3.2 %; P = 0.012). However, the rupture is contained in the majority of cases (67%) without tamponade or cardiogenic shock. Only two patients presented with aorto-atrial fistula and cardiogenic shock. These patients died despite aortic repair. Estera et al. [3] operated on two patients with aorto-pulmonary fistulas in the setting of aortic dissection in redo cases. Unfortunately, these two patients also died after the operation. Reports from the literature are sparse and sporadic [4]; rupture and haemodynamic instability are rare because of postcardiotomy scarring and protective periaortic fibrosis [5]. Aortic fistula to the right heart cavities is a dreaded complication that portends an incremental increased risk of mortality and dismal postoperative outcomes. As outlined in this case report, successful management requires timely recognition along with prompt surgical intervention. Conflict of interest: none declared.

A Rare complication of aorto-left atrial fistula after aortic valve replacement and its management with intraoperative transoesophageal echocardiography

Aorto-atrial fistula is a rare complication of prosthetic aortic valve replacement and most of them have been diagnosed as a late complication. We present a case of this unusual complication after aortic valve replacement which was diagnosed intraoperatively and this potentially disastrous complication was corrected promptly. Early recognition and diagnosis of this rare surgical complication with intraoperative transoesophageal echocardiography (TEE) is imperative for prompt surgical repair of this lethal defect.

Asymptomatic Aorto-atrial Fistula Identified With Intraoperative Transesophageal Echocardiography

With great interest, we read the report of Takahashi et al1 titled “Intraoperative Imaging and Off-Pump Ligation of Coronary Artery Fistula.” The management of coronary artery fistula (CAF) is indeed somewhat controversial, especially in younger, asymptomatic patients. It generally is agreed that symptomatic lesions and larger fistulae with significant shunting should be treated. Surgical ligation2 generally is accepted as the treatment of choice in CAF.

Successful Surgical Treatment of Intramural Aortoatrial Fistula, Severe Aortic Regurgitation, Mitral Prolapse, and Tricuspid Insufficiency in a Patient with Ehlers-Danlos Syndrome Type IV

Patients with Ehlers-Danlos syndrome (EDS) type IV, an inherited connective tissue disorder, are predisposed to vascular and digestive ruptures, and arterial ruptures account for the majority of deaths. A 31-year-old man with EDS presented with an intramural aortoatrial fistula, severe aortic regurgitation, mitral valve prolapse, and severe tricuspid valve insufficiency combined with a severely dilated left ventricle. Determining the best surgical option for the patient was not easy, especially regarding the course of action for the aortic root with a tear in the sinus of Valsalva. The fistula tract was closed at the aorta with suture and with a patch in the right atrium, the mitral valve was repaired with edge-to-edge suture and then annuloplasty with a Cosgrove ring, the aortic valve was replaced with a mechanical prosthesis, and a modified De Vega technique was used for the tricuspid valvuloplasty. The postoperative course was uncomplicated, and the patient was discharged 2 weeks later. The considerations made to arrive at the chosen surgical course of action in this complex case are reviewed.

Percutaneous Closure of an Aorto-Atrial Fistula After Surgery for Infective Endocarditis

A 44-year-old man was referred to the cardiology outpatient clinic due to dyspnea on exertion. He had undergone aortic valve replacement with a biological prosthetic valve (Carpentier-Edwards 23 mm, Edwards Lifesciences, Irvine, California) and reconstruction of the mitroaortic junction due to

Iatrogenic Atrial Septal Defect and Aortoatrial Fistula in a Patient With Endovascular Prosthesis in the Inferior Vena Cava

Percutaneous procedures and endovascular prostheses are becoming increasingly frequent, replacing classic interventions, and new complications are now appearing. We report the case of a liver transplant patient with a stenosis in the anastomosis of the suprahepatic veins to inferior vena cava, treated by self-expanding prosthesis, who developed an aorto-right atrial fistula and an atrial septal defect. Open heart surgery was performed to correct the defects. Transthoracic echocardiogram 1 year later revealed no evidence of residual shunt.