Ann Thorac Surg 2001;72:921-922
© 2001 The Society of Thoracic Surgeons
Case report
Aorto-atrial fistula through the septum in recurrent aortic dissection
Claudio Russo, MDa,
Francesca De Chiara, MDa,
Giuseppe Bruschi, MDa,
Guglielma Rita Ciliberto, MDa,
Ettore Vitali, MDa
a Departments of Cardiac Surgery and Cardiology, Ospedale Niguarda Ca’ Granda, Milan, Italy
Accepted for publication September 22, 2000.
Address reprint requests to Dr Russo, Department of Cardiac Surgery "A. De Gasperis," Ospedale Niguarda Ca’ Granda, Piazza Ospedale Maggiore, 3 20162 Milan, Italy
e-mail: cf.russo{at}tiscalinet.it
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Abstract
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A case of aortic dissection (De Bakey type I) with a fistula to the right atrium through the interatrial septum, diagnosed by transthoracic and transesophageal echocardiography is reported. The patient presented with cardiac failure and a continuous murmur in the right second and third intercostal spaces. The patient underwent successful operative repair.
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Introduction
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Aortic dissection with rupture into the right atrium is a rare complication and fatal if untreated [1]. Transthoracic echocardiography and the improved image quality of transesophageal echocardiography provide the capability of early diagnosis for an emergency operation.
The patient, a 70-year-old woman, obese, with insulin-dependent diabetes, was admitted into our hospital because of chest pain and dyspnea. At the same institution 6 years earlier she underwent emergency ascending aorta replacement with a 30 mm polyester vascular graft, Albograft (Sorin Biomedica Cardio S.p.A., Saluggia, Italy) for acute De Bakey type I aortic dissection. She was well until 4 days before the admission, when she experienced acute, severe precordial pain and dyspnea. She subsequently experienced orthopnea and pulmonary edema.
Physical examination revealed a blood pressure of 150/70 mm Hg, a heart rate of 100 beats/min, signs of congestive heart failure with pulmonary rales, and elevated jugular venous pressure. She had a grade 3/6 continuous systolic and diastolic murmur at the fourth intercostal space.
The electrocardiogram showed sinus tachycardia with an incomplete right bundle branch block pattern. Radiography of the chest showed pulmonary edema.
Despite intensive medical treatment, she had refractory and progressive heart failure. Transthoracic echocardiography showed a normal-sized left ventricle with hyperdynamic function. Right atrium and ventricle were both moderately dilated. The ascending aorta was abnormal with an adjacent echo-free space 2 cm distal to the aortic valve, representing the false lumen of an aortic dissection (Fig 1A). Color flow Doppler study in the apical four chamber view revealed a rent between the aorta and the right atrium with continuous flow (Fig 1B). Multiplane transesophageal echocardiography (performed with an Acuson Sequoia C 256, Acuson Corporation, Mountain View, CA) confirmed the diagnosis of remaining aortic root dissection and a communication between the noncoronary aortic sinus and right atrium; these findings looked consistent with a fistula to the right atrium from the dissected aorta through the interatrial septum. It was not possible to perform a coronary angiography because of aortic root severe deformation.
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Fig 1. (A) Transesophageal echocardiogram demonstrating the false lumen of the aortic dissection along the ascending aorta. (AO = ascending aorta; LA = left atrium; LV = left ventricle; RV = right ventricle.) (B) Transesophageal echocardiogram with color flow Doppler reveals bright mosaic color jet of high velocity originating within the aorta and entering the right atrium. (AO = ascending aorta; LA = left atrium; RA = right atrium.)
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The patient underwent an emergency operation. The chest was reopened through a middle resternotomy. Dense adhesions were present between the aortic prosthesis, the sternum, the superior vena cava, and the right atrium. Cardiopulmonary bypass was established and ascending aorta was cross-clamped in the upper part, beyond the distal anastomosis of the tubular prosthesis. Anterograde/retrograde blood cardioplegia was delivered continuously. The right atrium was opened. The aorta was entered at the level of proximal anastomosis, beyond the sinotubular junction.
The new dissection originated from the previous proximal anastomosis and was limited to the noncoronary sinus of Valsalva. Both the right and left coronary sinus did not show dissection. The aortic valve leaflets were morphologically normal, but the noncoronary cusp was prolapsing secondary to the dissection of the corresponding sinus. The intramedial dissection channel, getting through the aortic annulus corresponding to the same aortic sinus and the underlying interatrial septum, formed a fistula (3 x 1.5 cm) that perforated the right atrium wall; the outlet rupture was just 1.5 cm away from the coronary sinus ostium. The former vascular prosthesis was removed and a new one was implanted with reconstruction of the sinotubular junction at the level of the right and left coronary sinus. At the proximal end, the prosthesis was scalloped in order to reconstruct the dissected noncoronary sinus. The aortic annulus was reinforced with a felt strip. With this reconstruction, the cranial portion of fistula corresponding to sinus of Valsalva was eliminated. The lower part of the fistula, laying in the interatrial septum was obliterated with biological glue and the outlet rupture in the right atrium was sutured with pledget-reinforced sutures.
The distal end of the prosthesis was anastomosed to the distal ascending aorta. The right atriotomy was sutured.
Postoperative transesophageal echocardiography did not show any residual communication between the aorta and right atrium. The aortic valve appeared normal in function without insufficiency. The patient was extubated the day after the operation and discharged on postoperative day 10. At 3 months follow-up, she is alive, and functional in New York Heart Association’s class I.
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Comment
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This case describes an unusual complication of a previous operation of an aortic acute dissection. The frequency of aortocamera fistula in patients with previous operations suggests postoperative adhesions as pathogenetic mechanism [2]. This condition should be suspected in these kinds of patients, showing chest pain and cardiac failure, continuous murmur, and evidence of right ventricle volume overload. Transthoracic echocardiography and transesophageal echocardiography are the techniques of choice for diagnosis and allow for a prompt surgical repair [3].
In this case, the aortic valve sparing procedure allowed repair of the aorto-atrial fistula and avoided valve replacement with a prosthesis.
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References
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Page A.J.F., Yacoub M.H., Sutton G.C. Aorto-right atrial fistula: a rare complication of aortic dissection. Br Heart J 1973;35:1338-1340.[Free Full Text]
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Fujii H., Oka T., Kawaguchi H., et al. Aorto-atrial fistula associated with recurrent aortic dissection after ascending aorta replacement. J Cardiovasc Surg 1998;39:817-819.[Medline]
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Caruso A., Iarussi D., Materazzi C., Dialetto G., Covino F., Bossone E. Aortic dissection with fistula to left atrium: diagnosis by transesophageal echocaardiography with successful repair. J Am Soc Echocardiogr 2000;13:69-72.[Medline]
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Abstract
Introduction
