Download Aorto-Left Atrial Fistula

esophageal echocardiography. J Am Soc Echo 1991; 4:79-83
5 Reinstein SB, Shah PM, Bing RJ, et al. Microbubble dynamics
visualized in the intact capillary circulation. J Am Coll Cardiol
1984; 4:595-600
6 Durant TM, Long J, Oppenheimer J. Pulmonary (venous) air
embolism. Am Heart J 1947; 33:269-81
Aorto-Left Atrial Fistula*
A Reversible Cause of Acute
Refractory Heart Failure
Thomas P. Archer, MD; Scott W. Mabee, MD; Peter B. Baker,
MD; David A. Orsinelli, MD; and Carl V. Leier, MD
Fistulas between the
aorta
and left atrium, invari¬
ably a complication of aortic valvular endocarditis,
are rare and infrequently diagnosed premortem.
We describe a patient who presented with this
entity and review the reports of five other patients
for whom a diagnosis was made premortem. A
number of causative organisms have been identi¬
fied. The clinical course is characteristically one of
rapidly progressive heart failure. Notably, only
half of these fistulas were detected by transtho¬
racic echocardiography, whereas all were identi¬
fied by transesophageal echocardiography when
utilized. Once the diagnosis is made, prompt sur¬
gical repair is required to avert the high mortality
from rapidly developing refractory congestive
heart failure.
(CHEST 1997; 111:828-31)
aortic valve disease; aorto-atrial
Key words: aortic insufficiency;
fistula; congestive heart failure; echocardiography; infectious
endocarditis
"C1 istula tracts between the aorta and cardiac chambers
¦*-
are relatively uncommon. Virtually all reported aortocardiac fistulas involve communications between the aorta
and the right atrium, right ventricle, or left ventricle and
have been causally associated with bacterial endocarditis,
abscess, ruptured sinus of Valsalva aneurysm,
paravalvular
or aortic dissection.
Fistula formation between the aorta and left atrium,
associated with an endocarditic process, is quite
usually
rare.18 Furthermore, this diagnosis has been difficult to
establish premortem and occurred in only five previously
reported patients.1-5"8 We report a patient with valvularparavalvular endocarditis of the aortic valve complicated
by an aorto-left atrial fistula. In order to determine the
major clinical features of this condition, the clinical and
laboratory findings of the current patient and the previ¬
ously reported patients were compiled; these findings
form the basis of this report.
*From the Division of Cardiology, the Ohio State University
College of Medicine, Columbus. revision
13.
Manuscript received
May 20, 1996;
accepted 669
August
Means
of Cardiology,
Reprint1654requests: Dr. Leier, Division OH
Hall,
Upham Drive, Columbus, 43210-1228
Clinical
and
Laboratory Presentation
A 61-year-old man was transferred to the Ohio State University
Medical Center with fever, leukocytosis, severe congestive heart
failure, acute renal failure, delirium, and periods of obtundation.
His medical histoiy was significant for adult-onset diabetes
mellitus, systemic hypertension, alcoholism, smoking, and
COPD. He was seen at another medical center 3 weeks prior to
transfer; at that time, a diagnosis of Streptococcus pneumoniae
pneumonia was made, and broad-spectrum antibiotics were
prescribed. He continued to have recurrent fever, and over the
ensuing 3 weeks, he developed cardiac and respiratory failure. At
the time he was seen at our medical center, the physical
examination revealed an intubated man responding only to
painful stimuli. Spontaneous motor movement was noted only
along the right side. Rectal temperature was 38.9°C; heart rate,
97 beats per minute; and blood pressure, 140/40 mm Hg. Eye
findings included disconjugate gaze, pinpoint-sized pupils, and
poorly visualized fundi. Diffuse coarse rhonchi and bilateral
crepitant rales were noted. Auscultation of the heart was limited
by competing sounds and noise emanating from the chest. In this
patient, Sx and S2 were distant, and a II/VI harsh systolic murmur
was present along the right upper sternal border. A diastolic
murmur was not heard. Mild lower extremity edema was present
bilaterally.
Cardiomegaly and pulmonary vascular congestion were noted
on a chest radiograph. The ECG showed regular sinus rhythm
with PR prolongation (240 ms) and ST segment changes consis¬
tent with digitalis therapy. The WBC count was 16,000/mm3 with
5% band cells, 68% segmented polymorphonuclear leukocytes,
and 27% lymphocytes. The BUN was 80 mg/dL and the creati¬
nine level was 2.6 mg/dL. Readings from an indwelling pulmo¬
nary artery catheter were as follows: mean right atrial pressure,
12 mm Hg; mean pulmonary arteiy pressure, 97/45 mm Hg;
mean pulmonary arterial occlusive (capillary wedge) pressure, 36
mm Hg; and cardiac index, 1.9 L/min/m2. A transthoracic
echocardiogram was of poor quality; overall left ventricular
ejection fraction was estimated at 45% with no regional wall
motion abnormalities and no obvious aortic or mitral valvular
disease.
The patient was treated with broad-spectrum antibiotics, do¬
butamine, nitroprusside, furosemide, and ventilatory support.
Over the next 24 to 36 h, the patient improved neurologically
with increased responsiveness. A CT scan of the head revealed a
large right occipital ischemic infarct. Transesophageal echocar¬
diography, performed on the 2nd hospital day, demonstrated
vegetations on the noncoronary cusp of the aortic valve and on
the anterior leaflet of the mitral valve as well as an aortic
paravalvular abscess (Fig 1). Mild aortic and mitral regurgitation
were noted by color-flow Doppler echocardiography. In addition,
color-flow Doppler echocardiography detected continuous tur¬
bulent flow from the noncoronary sinus of Valsalva and adjacent
paravalvular abscess cavity to the left atrium; these findings were
consistent with
an aorto-left atrial fistula (Fig 1).
On the 3rd hospital day, the patient suffered a cardiac arrest en
route to cardiac surgery and died. Postmortem examination
revealed a large vegetation on the noncoronary cusp of the aortic
valve, a juxtaposed abscess cavity, and a fistulous tract that
connected the noncoronary sinus and paravalvular cavity to the
left atrium (Fig 2). The tract entered the left atrium above the
insertion of the anterior leaflet of the mitral valve, and a small
vegetation was present on the anterior leaflet of the mitral valve.
A splenic and multiple cerebral infarcts, moderate pulmonary
emphysema, and marked edema of the lungs also were noted.
828
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Selected
Reports
Figure 1. Top left: transesophageal echocardiographic view of
the aortic valve (AV) demonstrating a mass (single arrow at left)
consistent with a large vegetation on the noncoronary cusp. An
echo-free space (opposing arrows) is present between the aorta
and left atrium consistent with a paravalvular abscess cavity. Top
right:
transesophageal echocardiographic view of the proximal
aorta and left ventricle (LV) demonstrating a mass (marked by
two sets of double thin arrows) on the noncoronary cusp of the
aortic valve (AV) and the anterior leaflet of the mitral valve (MV).
The wide single arrow points to the fistulous connection between
the aorta and the left atrium (LA). Bottom right: same trans¬
esophageal
echocardiographic view as in Figure 1, top right, with
color-flow Doppler echocardiography.
*******'
Figure 2. The fistula tract, located between the arrows,
was
opened longitudinally during
the
postmortem examination. A necrotic cavity filled with blood clot comprised the central portion of the
fistula. Ao
=
aorta; LA
=
left atrium; NCC
=
noncoronary cusp of the aortic valve.
CHEST/111 73/MARCH, 1997
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829
Table 1.Clinical and Laboratory Features of the Reported Patients With Endocarditic Aorta to Left Atrium
Fistulas Diagnosed Premortem
Infecting
Aortic Valve
Patient
Source
Age, yr
Gender
Archer et al
61
M
(current
Anatomy
Tricuspid
patient)
Organism
S
Transthoracic
Echocardiography
pneumoniae Normal wall motion;
ejection fraction of
45%
Transesophageal
Echocardiography
Vegetations on the
noncoronary cusp of
aortic valve and
anterior leaflet of
mitral valve, mild
aortic and mitral
insufficiency, and
aorto-left atrial
Outcome
Severe heart failure
and death; findings
confirmed at autopsy
fistula; Doppler
echocardiography
showed continuous
flow from aorta to
left atrium
Behnam5
21
M
Tricuspid
Streptococcus
G
Aortic valve
with
Surgical correction
(improved)
vegetations
echolucent
cavity in the
an
posterior aortic root
and aorto-left atrial
fistula
Schwartz
18
M
etal6
Bicuspid
Staphylococcus Bicuspid aortic valve;
Surgical correction
(improved)
mild aortic
regurgitation;
echolucent cavity
between posterior
Thomas
Prosthetic
70*
etal1
Kelion
et
al8
Prosthetic
39
aortic vail and left
atrium; turbulent jet
from aortic root to
left atrium
None
An eccentric jet of
A fistula was identified
mitral regurgitation
identified;
joining the aortic
endocarditis
and continuous flow
root and the left
on the atrial side of
atrium; continuous
suspected
the mitral prosthesis
turbulent flow
between aorta and
left atrium
mimicking mitral
S viridans
Gross
thickening of the
mitral-aortic fibrosa;
communication from
the aorta to the left
atrium with a
continuous
Karalis
et
al'
28
M
Prosthetic
Candida
albicans
jet
Ill-defined echoes
surrounding the
aortic root with
thickening of the
root itself
Surgical correction
(early postoperative
death)
regurgitation
An aortic
paravalvular Surgical correction
(improved)
abscess with
fistulous
communication to
the left atrium
A paravalvular abscess
around the aortic
Cerebral hemorrhage
(death)
prosthesis; some
aortic
a
regurgitation;
fistulous
communication
between the abscess
cavity and the left
atrium
Summary:
Range:
18-70
yr
4
M;
2F
2
tricuspid; 1
bicuspid; 3
prosthetic
Varied
organisms
Endocarditis, 2 of 5;
Endocarditis, 3 of 3;
aorto-left atrial
fistula, 3 of 6
aorto-left atrial
fistula, 4 of 4
valves
Preoperative deaths, 2
of 2; postoperative
deaths, 1 of 4;
postoperative
recovery, 3 of 4
*This patient had prosthetic valvular dehiscence from
suspected but unproven bacterial endocarditis.
830
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Selected
Reports
esophageal echocardiography. J Am Soc Echo 1991; 4:79-83
5 Reinstein SB, Shah PM, Bing RJ, et al. Microbubble dynamics
visualized in the intact capillary circulation. J Am Coll Cardiol
1984; 4:595-600
6 Durant TM, Long J, Oppenheimer J. Pulmonary (venous) air
embolism. Am Heart J 1947; 33:269-81
Aorto-Left Atrial Fistula*
A Reversible Cause of Acute
Refractory Heart Failure
Thomas P. Archer, MD; Scott W. Mabee, MD; Peter B. Baker,
MD; David A. Orsinelli, MD; and Carl V. Leier, MD
Fistulas between the
aorta
and left atrium, invari¬
ably a complication of aortic valvular endocarditis,
are rare and infrequently diagnosed premortem.
We describe a patient who presented with this
entity and review the reports of five other patients
for whom a diagnosis was made premortem. A
number of causative organisms have been identi¬
fied. The clinical course is characteristically one of
rapidly progressive heart failure. Notably, only
half of these fistulas were detected by transtho¬
racic echocardiography, whereas all were identi¬
fied by transesophageal echocardiography when
utilized. Once the diagnosis is made, prompt sur¬
gical repair is required to avert the high mortality
from rapidly developing refractory congestive
heart failure.
(CHEST 1997; 111:828-31)
aortic valve disease; aorto-atrial
Key words: aortic insufficiency;
fistula; congestive heart failure; echocardiography; infectious
endocarditis
"C1 istula tracts between the aorta and cardiac chambers
¦*-
are relatively uncommon. Virtually all reported aortocardiac fistulas involve communications between the aorta
and the right atrium, right ventricle, or left ventricle and
have been causally associated with bacterial endocarditis,
abscess, ruptured sinus of Valsalva aneurysm,
paravalvular
or aortic dissection.
Fistula formation between the aorta and left atrium,
associated with an endocarditic process, is quite
usually
rare.18 Furthermore, this diagnosis has been difficult to
establish premortem and occurred in only five previously
reported patients.1-5"8 We report a patient with valvularparavalvular endocarditis of the aortic valve complicated
by an aorto-left atrial fistula. In order to determine the
major clinical features of this condition, the clinical and
laboratory findings of the current patient and the previ¬
ously reported patients were compiled; these findings
form the basis of this report.
*From the Division of Cardiology, the Ohio State University
College of Medicine, Columbus. revision
13.
Manuscript received
May 20, 1996;
accepted 669
August
Means
of Cardiology,
Reprint1654requests: Dr. Leier, Division OH
Hall,
Upham Drive, Columbus, 43210-1228
Clinical
and
Laboratory Presentation
A 61-year-old man was transferred to the Ohio State University
Medical Center with fever, leukocytosis, severe congestive heart
failure, acute renal failure, delirium, and periods of obtundation.
His medical histoiy was significant for adult-onset diabetes
mellitus, systemic hypertension, alcoholism, smoking, and
COPD. He was seen at another medical center 3 weeks prior to
transfer; at that time, a diagnosis of Streptococcus pneumoniae
pneumonia was made, and broad-spectrum antibiotics were
prescribed. He continued to have recurrent fever, and over the
ensuing 3 weeks, he developed cardiac and respiratory failure. At
the time he was seen at our medical center, the physical
examination revealed an intubated man responding only to
painful stimuli. Spontaneous motor movement was noted only
along the right side. Rectal temperature was 38.9°C; heart rate,
97 beats per minute; and blood pressure, 140/40 mm Hg. Eye
findings included disconjugate gaze, pinpoint-sized pupils, and
poorly visualized fundi. Diffuse coarse rhonchi and bilateral
crepitant rales were noted. Auscultation of the heart was limited
by competing sounds and noise emanating from the chest. In this
patient, Sx and S2 were distant, and a II/VI harsh systolic murmur
was present along the right upper sternal border. A diastolic
murmur was not heard. Mild lower extremity edema was present
bilaterally.
Cardiomegaly and pulmonary vascular congestion were noted
on a chest radiograph. The ECG showed regular sinus rhythm
with PR prolongation (240 ms) and ST segment changes consis¬
tent with digitalis therapy. The WBC count was 16,000/mm3 with
5% band cells, 68% segmented polymorphonuclear leukocytes,
and 27% lymphocytes. The BUN was 80 mg/dL and the creati¬
nine level was 2.6 mg/dL. Readings from an indwelling pulmo¬
nary artery catheter were as follows: mean right atrial pressure,
12 mm Hg; mean pulmonary arteiy pressure, 97/45 mm Hg;
mean pulmonary arterial occlusive (capillary wedge) pressure, 36
mm Hg; and cardiac index, 1.9 L/min/m2. A transthoracic
echocardiogram was of poor quality; overall left ventricular
ejection fraction was estimated at 45% with no regional wall
motion abnormalities and no obvious aortic or mitral valvular
disease.
The patient was treated with broad-spectrum antibiotics, do¬
butamine, nitroprusside, furosemide, and ventilatory support.
Over the next 24 to 36 h, the patient improved neurologically
with increased responsiveness. A CT scan of the head revealed a
large right occipital ischemic infarct. Transesophageal echocar¬
diography, performed on the 2nd hospital day, demonstrated
vegetations on the noncoronary cusp of the aortic valve and on
the anterior leaflet of the mitral valve as well as an aortic
paravalvular abscess (Fig 1). Mild aortic and mitral regurgitation
were noted by color-flow Doppler echocardiography. In addition,
color-flow Doppler echocardiography detected continuous tur¬
bulent flow from the noncoronary sinus of Valsalva and adjacent
paravalvular abscess cavity to the left atrium; these findings were
consistent with
an aorto-left atrial fistula (Fig 1).
On the 3rd hospital day, the patient suffered a cardiac arrest en
route to cardiac surgery and died. Postmortem examination
revealed a large vegetation on the noncoronary cusp of the aortic
valve, a juxtaposed abscess cavity, and a fistulous tract that
connected the noncoronary sinus and paravalvular cavity to the
left atrium (Fig 2). The tract entered the left atrium above the
insertion of the anterior leaflet of the mitral valve, and a small
vegetation was present on the anterior leaflet of the mitral valve.
A splenic and multiple cerebral infarcts, moderate pulmonary
emphysema, and marked edema of the lungs also were noted.
828
Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21745/ on 05/03/2017
Selected
Reports