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Table of Contents
CASE REPORT  
Year : 2014  |  Volume : 17  |  Issue : 2  |  Page : 155-156
Aortic root to left-atrial fistula after aortic valve replacement: A rare complication and its intraoperative management


1 Department of Cardiothoracic Surgery, Fortis Hospitals, Bengaluru, Karnataka, India
2 Department of Cardiac Anaesthesia, Fortis Hospitals, Bengaluru, Karnataka, India

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Date of Submission17-Oct-2013
Date of Acceptance18-Feb-2014
Date of Web Publication1-Apr-2014
 

   Abstract 

Aorto-atrial fistula is a rare complication of prosthetic aortic valve replacement (AVR) and most of them have been diagnosed as a late complication. We present a case of this unusual complication after AVR. Intraoperative transoesophageal echocardiography identified and diagnosed this rare and potentially disastrous surgical complication and confirmed adequacy of its surgical repair.

Keywords: Aortic valve surgery; Aorto-atrial fistula; Transoesophageal echocardiography

How to cite this article:
Ahmad T, Chithiraichelvan S, Patil TA, Jawali V. Aortic root to left-atrial fistula after aortic valve replacement: A rare complication and its intraoperative management. Ann Card Anaesth 2014;17:155-6

How to cite this URL:
Ahmad T, Chithiraichelvan S, Patil TA, Jawali V. Aortic root to left-atrial fistula after aortic valve replacement: A rare complication and its intraoperative management. Ann Card Anaesth [serial online] 2014 [cited 2020 Mar 29];17:155-6. Available from: http://www.annals.in/text.asp?2014/17/2/155/129872



   Introduction Top


Aortic root to left atrium (LA) fistula is a rare complication of prosthetic aortic valve replacement (AVR) and most of them have been diagnosed as a late complication. We present a case of this unusual complication after AVR which was diagnosed intraoperatively using transoesophageal echocardiography (TEE) and this potentially disastrous complication was corrected promptly.


   Case Report Top


A 71-year-old man presented with the complaints of angina. A transthoracic echocardiogram revealed a severe calcific aortic stenosis, mild aortic regurgitation and normal left ventricular function. Coronary angiogram showed normal coronaries. An intraoperative TEE confirmed the pre-operative findings and patient underwent aortic leaflets excision and annular debridement followed by AVR with a 21-mm pericardial bioprosthesis. After separation from cardiopulmonary bypass (CPB), TEE showed a well seated aortic prosthesis with a paravalvular leak which was noted throughout systole and diastole and did not originate from around the prosthetic sewing ring. A circuitous fistula from an echolucent area surrounding the non-coronary sinus of Valsalva to the LA was successfully traced [Figure 1]. The CPB was reestablished and the aorto-atrial fistula was closed with a pledgeted suture after opening LA. The patient was separated from CPB; the TEE showed a small residual jet [Figure 2] which disappeared completely after protamine administration [Figure 3].
Figure 1: A midesophageal aortic valve long-axis view showing aorto-atrial fistula (arrow) with color-flow traversing the aortic root and entering the left atrium

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Figure 2: Post-correction view showing mild systolic flow in left atrium

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Figure 3: Post-protamine view showing no flow in left atrium

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   Discussion Top


The complications of fistula formation between the aorta and either atrium are documented after aortic valve endocarditis [1],[2] and aortic dissection. [3] This complication has been rarely diagnosed in the early post-operative period after AVR. [4] Risk factors described include infected tissue before valve replacement, connective tissue abnormalities, extensive aortic annular debridement, and oversized aortic prostheses. [3] Various case reports describe late presentation of similar complications in patients who survived long. [1],[5] In another case report of similar aortic root to LA fistula complication, the communication was repaired without going back on CPB. [6] Several mechanisms of injury causing cardiac shunts during aortic valve surgery have been proposed, including inadvertent injury to the membranous septum during dissection below the non-coronary cusp, perivalvular damage attributable to improper retraction and excessive debridement of calcium from the annulus. [7]

Intraoperative TEE examination is a useful technique for an early diagnosis of this potentially disastrous complication. Aorto-atrial communications most often originate on the posterior aspect of the aortic annulus in the non-coronary sinus adjacent to the posterior commissure. TEE allows for imaging of small fistulous tracts because of its close proximity to the aortic root. [4] As a result, discrimination of a fistulous origin from normal blood flow becomes possible. TEE examination after separation from CPB can diagnose conditions that may necessitate surgical re-exploration such as prosthetic dehiscence, paravalvular leaks, and vascular injury. Ideally, the assessment should be made before administration of protamine, should reinstitution of CPB be required.

 
   References Top

1.Stechert MM, Kellermeier JP. Aorto-atrial fistula: An important complication of aortic prosthetic valve endocarditis. Anesth Analg 2007;105:332-3.  Back to cited text no. 1
    
2.Hilberath JN, Shook D, Shernan SK, Rosenberger P. Left ventricular outflow tract to right atrial fistula diagnosed by intraoperative transesophageal echocardiography. Anesth Analg 2007;104:261-2.  Back to cited text no. 2
    
3.Patsouras D, Argyri O, Siminilakis S, Michalis L, Sideris D. Aortic dissection with aorto-left atrial fistula formation soon after aortic valve replacement: A lethal complication diagnosed by transthoracic and transesophageal echocardiography. J Am Soc Echocardiogr 2002;15:1409-11.  Back to cited text no. 3
    
4.Ananthasubramaniam K. Clinical and echocardiographic features of aorto-atrial fistulas. Cardiovasc Ultrasound 2005;3:1.  Back to cited text no. 4
    
5.Samuels LE, Kaufman MS, Rodriguez-Vega J, Morris RJ, Brockman SK. Diagnosis and management of traumatic aorto-right ventricular fistulas. Ann Thorac Surg 1998;65:288-92.  Back to cited text no. 5
    
6.Azran MS, Fischer S, Guyton RA, Whitley WS. Early detection of aortic root to left atrial fistula after aortic valve replacement. Anesth Analg 2011;112:532-4.  Back to cited text no. 6
    
7.Eng MH, Garcia JA, Hansgen A, Chan KC, Carroll JD. Percutaneous closure of a para-prosthetic aorto-right ventricular fistula. Int J Cardiol 2007;118:e31-4.  Back to cited text no. 7
    

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Correspondence Address:
Tanveer Ahmad
#156, 3rd Cross, Shirdi Sai Nagar, Dr. Shivaram Karanth Nagar, Bengaluru - 560 077, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.129872

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    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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