Ann Thorac Surg 2004;78:2173-2175
© 2004 The Society of Thoracic Surgeons
Case report
Aorto-Right Atrial Fistula Caused by Type A Aortic Dissection
Hironori Matsuhisa, MDa,*,
Hidefumi Obo, MDa,
Keitaro Nakagiri, MDa,
Nobuhiko Mukohara, MDa,
Tsutomu Shida, MDa
a Department of Cardiovascular Surgery, Hyogo Brain and Heart Center at Himeji, Himeji, Hyogo, Japan
Accepted for publication August 6, 2003.
* Address reprint requests to Dr Matsuhisa, Department of Cardiovascular Surgery, Hyogo Brain and Heart Center at Himeji, 520 Saisyo-kou, Himeji, Hyogo 670-0981, Japan
hmatsuhisa{at}hbhc.jp
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Abstract
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We present a rare surgical case of aorto-right atrial fistula caused by type A aortic dissection in an 85-year-old man. Complaints included progressive general fatigue and anorexia caused by right side heart failure. However, there were no symptoms attributable to onset of the aortic dissection. A diagnosis of aorto-right atrial fistula was made from intraoperative transesophageal echocardiography. Total aortic arch replacement concomitant with direct closure of the fistula was performed successfully.
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Introduction
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Aorto-right atrial fistula is a rare complication of aortic dissection. Cardiac catheterization, transesophageal echocardiography (TEE), and magnetic resonance imaging are used for diagnosis. Immediate operation is required, because this fistula can cause progressive heart and multiple organ failures.
An 85-year-old Japanese male patient was referred to our hospital because of suspected aortic dissection. He had had progressive general fatigue and anorexia for 3 days. However, there was no obvious chest pain or back pain to imply the onset of aortic dissection. Laboratory data demonstrated acute dysfunction of the liver and kidney (total bilirubin 2.0 mg/dL, aspartate transaminase 217 IU/L, alanine transaminase 155 IU/L, blood urea nitrogen 73 mg/dL, and creatinine 2.2 mg/dL). Chest radiogram showed enlarged cardiac silhouette and the right-sided abnormal convexity due to extreme prominence of the ascending aorta (Fig 1).
Enhanced computed tomographic scan showed that the enlarged ascending aorta was 93 mm in diameter with mural thrombus in the false lumen. Because his general condition had been progressively deteriorating over a few days, and the extremely enlarged ascending aorta carried the risk of rupture, emergency surgery was performed. Intraoperative transesophageal echocardiogram demonstrated continuous blood flow from the false lumen of the aortic dissection to the right atrium and moderate aortic regurgitation. Therefore, the diagnosis of aorto-right atrial fistula complicated with type A aortic dissection was confirmed. Femorofemoral bypass was established before median sternotomy. The gigantic ascending aorta adhered densely to the pericardium, superior vena cava (SVC), and the right atrium. The thickened aortic wall suggested chronic dissection. A continuous thrill was palpated on the right atrium. The SVC was carefully dissected from the ascending aorta. The SVC cannula aspirated red oxygenated blood. The ascending aorta was opened. A 3-cm intimal tear was observed in the anterior wall of the aortic arch. The dissection extended from the sinotubular junction to the distal arch. The false lumen was filled with massive, old mural thrombus. After removal of the thrombus, a 5-mm fistula between the aorta and the right atrium was detected (Fig 2).
Under deep hypothermic circulatory arrest and antegrade selective cerebral perfusion, total aortic arch replacement was performed with a 28-mm four-limbed Hemashield graft (Meadox Medicals, Oakland, NJ), and the fistula was directly closed with 5-0 Prolene (Ethicon, Somerville, NJ). Since the aortic regurgitation was caused by the deformity of the sinotubular junction, plication of the sinotubular junction was performed. Postoperatively, liver and renal functions improved dramatically. Postoperative transthoracic echocardiography (TTE) showed normal left ventricular contraction without residual aortic regurgitation. The patient was discharged in good health on postoperative day 25.
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Comment
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Aortic dissection may cause various kinds of complications. Ruptures into the pericardial sac and into the pleural cavities are often complicated with aortic dissection. However, fistula formation to the cardiac chambers (right atrium, left atrium, and right ventricle) and the pulmonary artery are extremely rare complications of aortic dissection, and are life threatening [1, 2]. They also cause progression of congestive heart failure. Kuipers and Schatz [3] first reported rupture of a chronic dissection into the right atrium in 1963. According to their report, the diagnosis was made at autopsy. Temple and colleagues [4] reported the first successful surgical treatment of aorto-right atrial fistula complicated with aortic dissection. Their case was similar to our case. Initially, the onset of aortic dissection was uncertain. Second, aorto-right atrium fistula was complicated with chronic type A aortic dissection. Third, the symptoms were caused by right side heart failure. However, we have found no previous reports that aorto-right atrial fistula complicated with chronic aortic dissection induced acute liver and renal failure.
The aorto-right atrial fistula can be diagnosed by combination of physical examination, cardiac catheterization, TEE, and magnetic resonance imaging. If the patient's condition is stable, cardiac catheterization is the gold standard to detect aorto-right atrial fistula. However, our case required emergent surgical repair, because his condition was rapidly deteriorating. Therefore, we did not perform cardiac catheterization preoperatively, although we performed TTE first. However, we could not detect aorto-right atrial fistula by TTE. It was difficult to distinguish aorto-right atrial fistula from tricuspid regurgitation by TTE [5]. Transesophageal echocardiography is a useful noninvasive method to confirming a diagnosis of aorto-right atrial fistula because it can precisely localize the fistula; Doppler echocardiography can visualize the shunt flow. In addition, TEE can be performed intraoperatively.
Our patient was 85 years old. He is our oldest case of aorto-right atrial fistula complicated with aortic dissection. Although progressive hepatorenal failure developed, his postoperative course has been good.
In conclusion, aorto-right atrial fistula complicated with aortic dissection is extremely rare and life threatening. When such a diagnosis is made, immediate surgical intervention should be performed. Transesophageal echocardiography is a useful method of confirming the diagnosis.
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References
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- McGoldrick JP, Wells FC. Type 1 aortic dissection with right coronary artery occlusion and fistula to right atrium and right ventricle. Eur J Cardiothorac Surg. 1990;4:514–516[Abstract]
- Spier LN, Hall MH, Nelson RL, Parnell VA, Pogo GJ, Tortolani AJ. Aortic dissection: rupture into right ventricle and right pulmonary artery. Ann Thorac Surg. 1995;59:1107–1109[Abstract/Free Full Text]
- Kuipers FM, Schatz IJ. Prognosis in dissecting aneurysm of the aorta. Circulation. 1963;27:658–661[Abstract/Free Full Text]
- Temple TE Jr, Rainey RL, Anabtawi IN. Aortico-atrial shunt due to rupture of a dissecting aneurysm of the ascending aorta. J Thorac Cardiovasc Surg. 1966;52:249–254[Medline]
- Hsu RB, Chien CY, Wang SS, Chu SH. Aorto-right atrial fistula. A rare complication of aortic dissection. Tex Heart Inst J. 2000;27:64–66[Medline]
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Abstract
Introduction
