Aorto-right ventricular fistula as an occasional finding - EHJ ...

Eur J Echocardiography (2005) 6, 65e66
Aorto-right ventricular fistula
as an occasional finding
Jeroen Walpot ) , Cees Klazen, Raymond Hokken, Jetze Sorgedrager,
Martha Hoevenaar, Judith den Braber
Department of Cardiology, Ziekenhuis Walcheren, The Netherlands
Received 26 July 2004; revised 20 August 2004; accepted 24 August 2004
Available online 30 November 2004
KEYWORDS
Aorto-right ventricular
fistula;
Transesophageal
echocardiography
Case presentation
A 54-year-old man, with an unremarkable medical
history, was admitted to the hospital because of
stroke. He was treated with aspirin, dipyridamole,
statin and low molecular weight heparins. Transthoracic
echocardiography could not reveal structural
cardiac abnormalities. Holter tape recording
could not document atrial fibrillation. During
further work-up, transesophageal echocardiography
excluded an open foramen ovale, atrial septal
defect and intracardiac thrombosis. However, we
) Corresponding author. Department of Cardiology, Ziekenhuis
Walcheren, Koudekerkseweg 88, Postbus 3200, 4380 DD
Vlissingen, The Netherlands. Tel.: C31 118 425000; fax: C31
118 425331.
E-mail address: j.m.j.b.walpot@walcheren.ziekenhuis.nl
(J. Walpot).
Abstract Aorto-right ventricular fistulas are defects of the aortic wall in the area
above the right coronary cusp, where it separates aorta and right ventricular
outflowtract. Often, these injuries are due to trauma or infective endocarditis.
We report an occasional finding of such a fistula, without these causes. There
were no other abnormalities on the aortic valve, root or the ascending aorta.
ª 2004 The European Society of Cardiology. Published by Elsevier Ltd. All rights
reserved.
found a fistula between the aorta above the right
coronary cusp, and the right ventricular outflow
tract (Figs. 1 and 2). The aortic valve was normal
without regurgitation. Diameters of the aortic root
and ascending aorta were within normal limits.
There was no right ventricular overload. Endocarditis
prophylaxis and regular cardiac follow-up
were recommended.
Discussion
Aorto-cardiac fistulas are relatively rare. Often,
they are a complication of trauma or infective
endocarditis. 1e4
A2! 2 cm contact surface between the aorta
above the right coronary cusp and the right ventricular
outflow tract, is the target area for an
aorto-right ventricular fistula. 1
1525-2167/$30 ª 2004 The European Society of Cardiology. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.euje.2004.08.009
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66 J. Walpot et al.
Figure 1 TEE image at 135( with small aorto-right
ventricular shunt (S). LA Z left atrium, LV Z left ventricle,
AV Z aortic valve, MV Z mitral valve, AA Z ascending
aorta, fistula (F).
In a literature study, 1 5 of 18 patients with an
aorto-right ventricular fistula due to trauma
required emergency exploration because of
hemodynamic instability and there was a need
for surgery in 17 patients.
In a series 3 of 346 consecutive cases of infective
endocarditis, 9 patients were found to have an
aorto-cardiac fistula. Four of these had a ruptured
abscess of the right sinus of Valsalva. Mortality in the
patients with aorto-cardiac fistulas was high (55%).
In another series, 4 of 106 cases of endocarditis,
6 patients with a cardiac fistula were found and 2
of them had an aorto-right ventricular fistula.
In a literature study 5 of 175 cases, the major
cause of an aorto-cardiac fistula (76%) was a rupture
of a congenital aortic sinus aneurysm.
In conclusion, we report the case of a patient
with an aorto-right ventricular fistula as an occasional
finding. Neither infective endocarditis, nor
trauma was the cause of this lesion. Also, with the
Figure 2 TEE image at 42( demonstrating the aortoventricular
shunt (F). LA Z left atrium, LV Z left ventricle,
AV Z aortic valve, RV Z right ventricle, AA Z
ascending aorta, S Z shunt, PI Z pulmonary insufficiency.
exception of aorto-right ventricular fistula, there
were no other abnormalities on the aortic valve,
the aorta root and the ascending aorta.
References
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Aortocardiac fistula with aortic valve injury from penetrating
trauma. J Trauma 1986;26(3):266e70.
2. Siavelis HA, Marsan R, Marshall WJ, Maull K. Aortoventricular
fistula secondary to blunt trauma: a case report and review
from the literature. J Trauma 1997;43(4):713e5.
3. Anguera I, Quaglio G, Miro JM, Pare C, Azqueta M, Marco F,
et al. Aortocardiac fistulas complicating infective endocarditis.
Am J Cardiol 2001;87(5):652e4.
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A, Pandya A, et al. Annular abscesses in surgical endocarditis:
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