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Ann Thorac Surg 1998;65:288
© 1998 The Society of Thoracic Surgeons

Current Reviews

Diagnosis and Management of Traumatic Aorto–Right Ventricular Fistulas

Louis E. Samuels, MD, Marla S. Kaufman, BA, Jose Rodriguez-Vega, MD, Rohinton J. Morris, MD, Stanley K. Brockman, MD

Department of Cardiothoracic Surgery, Allegheny University Hospital, Hahnemann Division, Philadelphia, Pennsylvania, USA

Dr Samuels, Department of Cardiothoracic Surgery, Allegheny University Hospital, Hahnemann Division, Broad & Vine Sts, MS 111, Philadelphia, PA 19102.


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
Background. Traumatic aorto–right ventricular (Ao-RV) fistulas are rare lesions that result in congestive heart failure if left untreated. Early diagnosis and prompt surgical intervention are required to avoid the natural outcome of cardiac decompensation.

Methods. All cases of traumatic Ao-RV fistula described in the English literature since 1958 were reviewed. The clinical presentation, methods of diagnosis, and treatment strategies were assessed to determine the pathophysiology, natural history, and outcome of surgical intervention.

Results. Forty cases of traumatic Ao-RV fistulas were described in the English literature. There were 39 men and 1 woman, with a mean age of 28.3 years (range, 15 to 50 years). Twenty-two (55%) patients had isolated Ao-RV fistulas. Fourteen (35%) had Ao-RV fistulas with aortic insufficiency. Definitive surgical repair was performed in 38 patients. The associated aortic valve injuries were managed with repair techniques or replacement with prosthetic devices. The surgical outcomes in all patients were satisfactory.

Conclusions. The pathophysiology and natural history of Ao-RV fistulas involves the development of congestive heart failure. Traumatic aortic insufficiency frequently is associated with this disorder. Early diagnosis and prompt treatment are necessary to avoid the natural outcome of cardiac decompensation. Definitive repair should be performed with the aid of cardiopulmonary bypass during the same hospitalization.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 References
 
It has been a century since Rehn [1] performed the first successful cardiorrhaphy in a man for penetrating trauma, and 40 years since King and Shumacker [2] reported the first repair of a traumatic aorto-right ventricular (Ao-RV) fistula. Among the intracardiac lesions that result from penetrating trauma to the heart, Ao-RV fistulas are rare. In a review of the literature, we were able to identify 40 previous cases (Table 1). In several large series of patients with penetrating heart wounds [3][4], no Ao-RV fistulas were identified. It has been stated that the incidence of intracardiac defects in patients with penetrating cardiac trauma is 3% to 5% [5]. According to others [4][6][7], the incidence is 2% to 3%. In a report by Beall and associates [8], the overall incidence of intracardiac defects was 1.25% and the incidence of Ao-RV fistulas was 0.5%. Because of the small experience with this lesion, the pathophysiology and natural history of traumatic Ao-RV fistulas is incomplete. Our review enabled us to formulate a definitive diagnostic and therapeutic plan for the management of this problem. The following discussion represents our examination of traumatic Ao-RV fistulas and the rationale for our current approach.


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  		Review of Traumatic Aorto-Right Ventricular Fistulas

 

   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
All 40 cases of traumatic Ao-RV fistula described in the English literature since 1958 were reviewed in detail. The clinical presentation, methods of diagnosis, and treatment strategies were assessed with respect to outcome. We compared these findings with a recent case at our institution.

A 26-year-old man was transferred to Allegheny University Hospital, Hahnemann Division, in Philadelphia, Pennsylvania for evaluation and management of a self-inflicted stab wound to the chest on December 20, 1995. The past medical history was significant for depression. In the emergency department, the patient was awake and responsive, with stable vital signs. Breath sounds were clear to auscultation bilaterally. No thrill or murmur was appreciated over the precordium. There was a 1-cm stab wound in the left parasternal region between the third and fourth intercostal spaces. Plain roentgenography of the chest was normal. There was sinus tachycardia on the electrocardiogram. A small pericardial effusion was detected by transthoracic echocardiography.

The patient was taken to the operating room for exploration. A median sternotomy was performed. The pericardium was opened and a hemopericardium was released. A perforation of the right ventricle was repaired with 3-0 silk mattress Teflon (Deknatel, Fall River, MA)-pledgeted suture. A continuous thrill along the right ventricular outflow tract was palpated. An ecchymotic ascending aorta was observed. These findings were suggestive of an Ao-RV fistula.

A transesophageal echocardiography probe was placed while blood samples were obtained from the right atrium, right ventricle, pulmonary artery, and aorta. Oxygen saturations at these sites were 65%, 80%, 80%, and 98%, respectively. A fistula between the aorta and right ventricle at the level of the right coronary sinus was demonstrated by transesophageal echocardiography (Fig 1). There was no injury to the aortic valve. In view of the patient’s hemodynamic stability, the decision was made to conclude the operation and repair the fistula after full cardiac catheterization and aortic angiography had been performed.



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  		Demonstration of aorto–right ventricular fistula on transesophageal echocardiography. (Ao = aorta; F = fistula; RCA = right coronary artery; RV = right ventricle.)

 
On the second hospital day, cardiac catheterization and aortic angiography were performed. An Ao-RV fistula was identified. No other pathology was noted. The shunt was 1.7:1. On the third hospital day, the patient underwent surgical repair. A transesophageal echocardiography probe was placed intraoperatively. Repeated sternotomy was performed and cardiopulmonary bypass was established. Electromechanical arrest was achieved with standard antegrade cardioplegia. The right ventricle was compressed to prevent cardioplegia from flowing through the fistula and causing right ventricular distention. A transverse aortotomy was made 2 cm above the aortic valve. A 1-cm laceration was observed 3 mm below the os of the right coronary artery. Inspection of the aortic valve showed a minor abrasion of the right leaflet. The laceration was repaired with Teflon-pledgeted 4-0 polypropylene (Prolene; Ethicon, Somerville, NJ) sutures in a mattress fashion. After weaning from cardiopulmonary bypass, the thrill in the right ventricular outflow tract was gone and transesophageal echocardiography no longer showed the fistula. The hospital course was unremarkable and the patient was discharged on the fifth postoperative day.


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
Forty patients with Ao-RV fistula have been described in the English literature since 1958 [2][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35]. With one exception [33], all the patients were men. Their mean age was 28.3 years (range, 15 to 50 years). The mechanisms of injury were 35 (88%) stab wounds, 4 (10%) gunshot wounds, and 1 (2%) cartridge explosion. The presenting features of 27 patients at the time of injury were described in detail [2][9][10][12][13][14][15][16][17][18][19][23][24][26][27][28][29][30][31][33]. Twenty-one (78%) patients were admitted with shock, 2 (7%) with tachycardia, and 4 (15%) with stable vital signs. Initial resuscitative procedures were performed in 17 patients, including 6 pericardiocenteses, 3 thoracenteses or tube thoracostomies, and 8 combined procedures. Immediate thoracic exploration was performed in 14 patients and abdominal exploration in 3. The majority were thoracotomies with repair of right ventricular lacerations. In only 1 patient [17] was the Ao-RV fistula repaired at the initial exploration.

The presence of a continuous murmur was described in 29 patients. A continuous murmur was detected on admission in 9 patients (31%), in the operating room in 2 (7%), the next day in 4 (14%), between 2 and 7 days later in 4 (14%), and more than 1 week later in 10 (34%). The mean interval from the injury to the detection of the murmur was 59 days (range, 1 day to 3 years). Twenty-two patients (55%) had isolated Ao-RV fistulas, 14 (35%) had Ao-RV fistulas with aortic insufficiency, and 4 (10%) had Ao-RV fistulas combined with traumatic atrial septal defect, ventricular septal defect, or mitral regurgitation. Twelve patients had shunt fractions greater than 1.5:1. Definitive surgical repair of the Ao-RV fistula was performed in 38 of the 40 patients. Two of the 4 asymptomatic patients did not undergo repair. The mean interval between the time of injury and definitive repair was 1.5 years (range, 1 day to 17 years) (Table 1).

Excluding the 5 outliers [13][21][25][26], the mean interval to definitive repair was 62 days. Twenty-eight patients (88%) were symptomatic and 4 were asymptomatic when they presented for definitive repair. The symptoms of 8 patients were not described. Congestive heart failure developed in 23 (72%) patients and endocarditis in 2 (6%); 1 patient presented with cardiac tamponade and 1 with hypotension. Definitive repair required cardiopulmonary bypass in all cases. Fifteen patients were repaired with a right ventriculotomy alone, 8 with an aortotomy alone, and 6 with combined aortotomy and ventriculotomy. The fistulas were closed with 2-0, 3-0, 4-0, or 5-0 silk, Tevdek (Deknatel), Mersilene (Ethicon), or Prolene in a simple interrupted, Fig 1-of-eight, mattressed, and, frequently, Teflon-buttressed fashion. The associated aortic valve injuries were managed successfully with a variety of techniques, including the use of Teflon (Bahnson) cusps [13], a leaflet from an aortic valve homograft [17], aortic valve replacement with a Starr-Edwards prosthesis (Baxter, Irvine, CA) [19], creation of a bileaflet aortic valve [21], pericardial gussets sewn over the perforations [26], and several valvuloplasty techniques using interrupted 5-0 Dacron [26] and 6-0 Prolene [28][31] suture. The surgical outcomes in all cases were satisfactory. Several authors [10][15][28], however, commented on the extensive adhesions encountered during the reoperation or delayed primary operation, particularly over the right ventricular outflow tract.


   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
Penetrating cardiac trauma has been managed successfully for more than a century. Simple cardiac wounds were treated without the aid of extracorporeal circulation before 1950. With the advent of cardiopulmonary bypass in 1953, more complex intracardiac lesions were managed successfully. Traumatic Ao-RV fistulas are rare lesions within the setting of penetrating cardiac injuries. Although several case reports and small series [2][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35] have described this entity, no definitive plan regarding its treatment has been established.

The pathophysiology and natural history of traumatic Ao-RV fistulas involves the development of congestive heart failure. Although well tolerated initially, these lesions result in cardiac decompensation over a variable period. The right ventricular strain caused by the fistula may be accompanied by left ventricular strain from associated aortic insufficiency. This frequent combination may explain the development of symptoms that are out of proportion to the calculated left-to-right shunts. Thus, any policy to decide on surgical intervention on the basis of a shunt fraction is subject to error.

The idea that Ao-RV fistulas can be observed and managed nonoperatively with the hope of spontaneous closure or a clinically benign course has no foundation. The experience with traumatic ventricular septal defects and the occasional case of spontaneous closure [36][37] cannot be translated to Ao-RV fistulas. The anatomy of the two lesions is different. Whereas traumatic ventricular septal defects occur most commonly in the muscular septum, traumatic Ao-RV fistulas generally violate the perimembranous septum. As hypothesized by Thandroyen and Matisonn [27], if a traumatic ventricular septal defect is small (ie, less than 0.5 to 1.0 cm), it may seal spontaneously as a result of spasm of the muscular ventricle or clot formation around the wound. In addition, as suggested by Rayner and colleagues [38], shunts with pulmonary blood flow less than 1.8 times systemic blood flow are compatible with a long-term asymptomatic course, provided there is no associated valve or coronary vessel damage.

As we have shown, aortic valve injury is a common associated feature, with aortic insufficiency contributing to the pathophysiology and natural history of Ao-RV fistulas. Spontaneous closure of Ao-RV fistulas never has been documented. On the contrary, there is a propensity for the shunts in Ao-RV fistulas to remain open and increase in magnitude over time [14]. Several authors [35][39][40][41] have observed and addressed the issue of delayed sequelae of penetrating cardiac injury. Whether the clinical manifestations of an Ao-RV fistula develop immediately or weeks, months, or years after the injury is not as important as treating the lesion once it is identified. There is no role for medical therapy or justification for observation except under conditions in which cardiopulmonary bypass and full heparinization may be contraindicated or other conditions of the patient assume higher priority.

The development of a continuous murmur in the setting of penetrating chest trauma requires thorough investigation. The absence of clinically significant cardiac symptoms should not eliminate the possibility of an underlying intracardiac lesion. Simple investigational maneuvers include the placement of a Swan-Ganz catheter to obtain blood gas saturations for evaluation of a step-up. Performance of transthoracic or transesophageal echocardiography to demonstrate and define intracardiac pathology is simple to obtain. Transthoracic and transesophageal echocardiography have become well-established and accepted screening tools in the setting of penetrating cardiac trauma, and their application to specific intracardiac conditions has been described [34][42][43][44]. If circumstances do not allow for these maneuvers initially, they can be obtained intraoperatively (as described in our case) or postoperatively. Because Ao-RV fistulas are well tolerated and repair requires cardiopulmonary bypass, definitive surgical intervention can be delayed until evaluation is completed with full cardiac catheterization and aortic angiography. In addition, any concerns regarding heparinization and cardiopulmonary bypass can be addressed in the interim. However, we do recommend early repair, preferably during the same hospitalization. Early repair has several advantages: (1) it avoids the cardiac decompensation that inevitably occurs in most of these patients, (2) it lessens the risk of endocarditis, (3) it avoids the formation of extensive adhesions that make reoperations more difficult, (4) it allows for a simple repair of a clean laceration as opposed to the repair of a long-standing fistulous tract, (5) it avoids loss to follow-up, and (6) it eliminates the need for frequent outpatient evaluations to determine whether and when operation should be performed.

In summary, we have outlined the pathophysiology of traumatic Ao-RV fistulas on the basis of our review of 40 patients. The natural history of the condition includes the development of congestive heart failure if left untreated. The clinical suspicion of such a lesion is based on the presence of a continuous murmur or palpable thrill over the precordium in the setting of penetrating thoracic trauma. Simple maneuvers, including blood gas saturations from the right heart and echocardiography, can be obtained quickly and easily in the emergency department, operating room, or intensive care unit. Evaluation with cardiac catheterization and aortic angiography defines the pathology completely in preparation for definitive correction. Surgical repair can be performed on a semielective basis, preferably during the same hospital admission. Recovery is swift and uncomplicated. This approach represents the safest, simplest, and most efficient means of managing this problem.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

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