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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 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 Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21745/ on 05/03/2017 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 Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21745/ on 05/03/2017 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