Three‐Dimensional Transthoracic Echocardiography in Identification of Aorto‐Right Atrial Fistula and Aorto‐Right Ventricular Fistulas

Abstract

We report the case of a 72-year-old woman who developed new onset right ventricular failure after redo aortic valve replacement. The diagnosis of left to right shunt was initially made using two-dimensional transthoracic echocardiography (2DTTE) and 2D transesophageal echo with color Doppler (TEE). Definite diagnosis of aorto-right atrial and aorto-right ventricular fistula was made using three-dimensional transthoracic echocardiography (3DTTE) with color flow Doppler imaging. Early recognition and diagnosis of this rare surgical complication is imperative for prompt surgical repair of this lethal defect. 3DTTE should be utilized in cases of new onset heart failure with unclear etiology to diagnose unusual causes of this potentially fatal condition.

Aorto-right ventricular fistula: An early complication of aortic valve replacement

“…No documented case of spontaneous closure was reported and shunts in ARV fistula are indeed characterized by their propensity to increase in size overtime [23] . ARV fistulas are known to be highly morbid leading often to heart failure as major complication and mortality exceeded 40% when associated to infective endocarditis [10,13] .…”

“…TEE is more useful rather than TTE to assess deeply valve function and to define accurately shunt morphology and volume. Currently, three-Dimensional trans-thoracic echocardiography is increasingly widespread and provides therefore better special orientation combined with color flow mapping to identify promptly fistulas [10] . Diagnosis may also be made by cardiac catheterization, magnetic resonance imaging or multi-slice computed tomography may demonstrate ARV fistula [22] .…”

“…According to a series of 310 patients with aortic valve replacement and found only 1 case of fistula from the aorta to the right atrium as well as the RV, thereby the incidence seems to be less than 0.5% [6] . Often, ARV fistulas are a complication of penetrating chest trauma [7,8] or most typically of infective endocarditis [9,10] . In the other hand, ARV fistula may follow a rupture of a congenital aortic sinus aneurysm [11] .When occurring in infective endocarditis, ARV fistula is associated with gloomy prognosis because of higher mortality (55% according to a series of 346 consecutive cases of infective endocarditis) [12] .…”

“…Indeed, ARV fistula may follow either surgical aortic valve replacement [1,15] or percutaneous aortic valve implantation (TAVI) [16] . Several mechanisms may lead to cardiac shunts during aortic valve surgery including unintentional injury to the membranous septum sustained during dissection below the noncoronary cusps, perivalvular damage attributable to improper retraction and excessive and aggressive debridement of bulky areas of calcification from the aortic annulus [5][6][7][8][9][10][11][12][13][14][15][16][17] and/or pseudo-aneurysm formation secondary to degenerative changes at the aortotomy line and the pseudo-aneurysm's eventual rupture into the RV [1] . Lorenz et al proposed ischemic necrosis because of inappropriate suturing of the mechanical valve if the membranous portion of the ventricular septum is included in the prosthetic valve suture line [5] .…”

Hot-Air Balloon Explosion in the Heart

“…Echocardiography is considered the first choice to detect this lesion and transesophageal echocardiographic examination, or 3-dimensional echocardiographic scan, when possible, offers a better sensitivity and specificity. 4 Advanced imaging such as MRI and computed tomography may allow definitive diagnosis in elective cases, 3 whereas cardiac angiography may be required in case of hemodynamic instability to define surgical anatomy. When accurately and promptly recognized, surgical management of congenital aorto-right atrial fistula is a low-risk procedure with favorable long-term outcome.…”