Ann Thorac Surg 2005;80:2362-2364
© 2005 The Society of Thoracic Surgeons
Case report
Traumatic Aorto-Right Ventricular Fistula With Aortic Insufficiency
Abdullah Kaya, MD
a
,
*
,
Paul Dekkers, MD
b
,
Antonino Loforte, MD
a
,
Wybren Jaarsma, MD, PhD
b
,
Wim J. Morshuis, MD, PhD
a
a Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
b Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
Accepted for publication July 29, 2004.
* Address correspondence to Dr Kaya, Department of Cardiothoracic Surgery, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, the Netherlands (Email: a_kaya33{at}hotmail.com).
 |
Abstract
|
|---|
We present a case of a traumatic aorto-right ventricular fistula coexistent with aortic insufficiency due to perforation of the left coronary leaflet, which is a lesion rarely described in the literature. We compare our experience with reports from the literature.
|
Introduction
|
|---|
Since the first case report of traumatic aorto-right ventricular fistula in 1958, there have been 42 case reports in literature [1–3]. Only 17 of these describe the combination of traumatic aorto-right ventricular fistula with aortic insufficiency [2, 3]. We present a case of an aorta to the right ventricular fistula combined with aortic insufficiency after a penetrating trauma. The aim is to compare our experience with the various approaches described in the literature.
A 19-year-old man was stabbed with a small bladed stiletto knife in the left third intercostal space adjacent to the sternum. On admission, the patient was alert and responsive with stable vital signs. There was no significant past medical history or medication. There was no thrill or murmur heard on examination. Chest roentgenogram showed fluid in the left hemithorax. A mild to moderate amount of pericardial effusion associated with left-sided pleural fluid was detected by transthoracic echocardiography. Mild aortic valve insufficiency and a small ventricular septal defect was also seen (Fig 1). Unfortunately the patient refused transesophageal echocardiography, which could have given more detailed information about the pathology. A left-sided chest drain produced 1,270 mL of serosanguineous fluid over a 2-day period. At reevaluation by transthoracic echocardiography the findings were unchanged. The patient was hemodynamically stable and maintained adequate oxygen saturation. He had no complaints and was optimally mobilized. He made an uneventful recovery and insisted on being discharged against medical advice. He did not report for follow-up at the outpatient clinic. A month later he was urgently readmitted due to severe dyspnea. A continuous pre-cordial murmur was heard on auscultation and congestion of his jugular veins was evident. Pericardial tamponade was confirmed by transthoracic echocardiography and a subxiphoid pericardiocentesis was performed with 1,060 mL of blood evacuated. Reevaluation with transthoracic echocardiography confirmed moderate aortic valve regurgitation, an increased left to right shunt between the aortic root and the right ventricular outflow tract, and a moderately dilated right ventricle (Fig 1). At surgery, a median sternotomy was performed, the pericardium was opened, and the epicardial adhesions were released. On cardiopulmonary bypass with double venous cannulation, cold crystalloid cardioplegia was selectively infused through the coronary ostia until a septal temperature of 10°C was achieved. The aorto-right ventricular communication was exposed through the transverse aortotomy. An imaginary line could be drawn from the lacerated left coronary cusp, crossing the interleaflet triangle between the left and right coronary cusp, penetrating the right ventricular outflow tract (Fig 2). A small opening was also noticed in the pericardium covering the right ventricle, thus confirming the trajectory of the penetrating injury. No superficial entry wound was found on the right ventricle, probably due to the adhesions. The septal communication was closed through the aortotomy with continuous 5-0 polypropylene suture. A small (5 mm) clean cut longitudinal laceration at the base of the left coronary cusp of the aortic valve could be repaired primarily with a double layer continuous 7-0 polypropylene suture (Fig 2). Postoperatively to the repair, an intraoperative transesophageal echocardiographic evaluation showed no evidence of aortic valve insufficiency or left to right shunt. The postoperative course was uneventful and the patient was discharged on postoperative day 5. To our disappointment, thus far the patient has continued to abstain from following up at the outpatient clinic.
View larger version (87K):
[in this window]
[in a new window]
|
Fig 1. Parasternal short axis view showing increased left to right shunt (arrow) after 1 month. (Ao = aorta; RA = right atrium; RV = right ventricle; RVOT = right ventricular outflow tract.)
|
|
View larger version (26K):
[in this window]
[in a new window]
|
Fig 2. Artist impression of an intracardiac direction of penetrating injury (arrow). Inset: postoperative repair diagram of left coronary cusp (asterisk). (LCC = left coronary cusp; LCO = left coronary ostium; RVOT = right ventricular outflow tract.)
|
|
|
Comment
|
|---|
Traumatic aorto-right ventricular fistulas with aortic insufficiency are rare lesions after penetrating thoracic injuries. According to the literature this specific lesion has been reported 17 times previously [2, 3].
The time interval between injury and surgical intervention is variable. Some patients require immediate surgical management due to instable hemodynamics, but others may have a delayed clinical presentation and therefore a delayed repair [3–5]. The interval until definitive repair could be as long as 17 years, as reported by Ehrenstein and colleagues [6]. In this case, the time interval between injury and repair was 56 days. The propensity for shunts in aorto-right ventricular fistulas to increase in size with time may explain the delayed time interval to definitive repair as reported by some authors [3–5, 7]. All patients with a traumatic aorta to right ventricular fistula combined with aortic insufficiency (except for one patient) were operated on sooner or later, as reported in the review by Samuels and colleagues [2]. Our experience confirms that a traumatic aorto-right ventricular shunt with aortic insufficiency has a tendency to increase in size with time. Therefore it is advisable that these patients be operated on at an early stage.
Although patients with aorto-right ventricular fistula combined with aortic insufficiency after a penetrating trauma may have no cardiac symptoms, they should be thoroughly evaluated, preferably by transesophageal echocardiography, and operated on during the same admission. If left untreated, congestive heart failure will invariably develop.
|
References
|
|---|
- King H, Shumacker Jr HB. Surgical repair of a traumatic aortic-right ventricular fistula J Thorac Surg 1958;35:734-739.
- Samuels LE, Kaufman MS, Rodriguez-Vega J, Morris RJ, Brockman SK. Diagnosis and management of traumatic aorto-right ventricular fistulas Ann Thorac Surg 1998;65:288-292.[Abstract/Free Full Text]
- Hibino N, Tsuchiya K, Sasaki H, Matsumoto H, Nakajima M, Naito Y. Delayed presentation of injury to the sinus of valsalva with aortic regurgitation resulting from penetrating cardiac wounds J Card Surg 2003;18:236-239.[Medline]
- Klinkenberg TJ, Kaan GL, Lacquet LK. Delayed sequelae of penetrating chest traumaa plea for early sternotomy. J Cardiovasc Surg 1994;35:173-175.
- Sherron SR, Bates M, Booth DC. Delayed presentation of aorto-right ventricular fistula after stab wound to the chest Cathet Cardiovasc Diagn 1995;35:136-138.[Medline]
- Ehrenstein FL, Bahler RC, Ankeny J, Swartz H. Untreated (combined) intracardiac and valvular trauma with long asymptomatic survival Am Heart J 1971;81:685-687.[Medline]
- Summerall III CP, Lee Jr WH, Boone JA. Intracardiac shunts after penetrating wounds of the heart N Eng J Med 1965;272:240-242.
This article has been cited by other articles:
|
|
|
|
 
S. Rubin, P. E. Falcoz, A. Poncet, and B. Baehrel
Traumatic aorto-right atrial fistula and tricuspid valve rupture. Post-operative cardiac and respiratory support with extracorporeal membrane oxygenation
Interactive CardioVascular and Thoracic Surgery,
December 1, 2006;
5(6):
735 - 737.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
