Asymptomatic aorto-atrial fistula identified with intraoperative transesophageal echocardiography

Aortic pseudoaneurysm with a fistula between the non-coronary sinus and right atrium: a case report

The authors present a case report of a 68-year-old man evaluated at the emergency department for repeated syncope, asthenia, and general malaise, suggesting heart failure in a patient with several comorbidities. At presentation, the patient was afebrile, but he had reported a low-grade fever in the previous six months. At first glance, transthoracic echocardiography was not clear, while transesophageal echocardiography revealed an echo-free image at the level of the non-coronary sinus of the aortic root, suggestive of a pseudoaneurysm, communicating with the right atrium with continuous systo-diastolic flow, compatible with the aorto-cavitary fistula between the aortic root and the RA. Echocardiographic findings were confirmed by cardiac computed tomography. The case was discussed with the heart team and was considered suitable for surgery, but the patient suddenly died just before surgery due to impairment and friability.

Aortic Fistulas: Pathophysiologic Features, Imaging Findings, and Diagnostic Pitfalls

Fistulas between the aorta and surrounding organs are extremely rare but can be fatal if they are not identified and treated promptly. Most of these fistulas are associated with a history of trauma or vascular intervention. However, spontaneous aortic fistulas (AoFs) can develop in patients with weakened vasculature, which can be due to advanced atherosclerotic disease, collagen-vascular disease, vasculitides, and/or hematogenous infections. The clinical features of AoFs are often nonspecific, with patients presenting with bleeding manifestations, back or abdominal pain, fever, and shock. Confirmation with invasive endoscopy is often impractical in the acute setting. Imaging plays an important role in the management of AoFs, and multiphasic multidetector CT angiography is the initial imaging examination of choice. Obvious signs of AoF include intravenous contrast material extravasation into the fistulizing hollow organ, tract visualization, and aortic graft migration into the adjacent structure. However, nonspecific indirect signs such as loss of fat planes and ectopic foci of gas are seen more commonly. These indirect signs can be confused with other entities such as infection and postoperative changes. Management may involve complex and staged surgical procedures, depending on the patient's clinical status, site of the fistula, presence of infection, and anticipated tissue friability. As endovascular interventions become more common, radiologists will need to have a high index of suspicion for this entity in patients who have a history of aneurysms, vascular repair, or trauma and present with bleeding. Online supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article. ^©RSNA, 2021.

Aorto-cardiac fistula etiology, presentation, and management: A systematic review

BACKGROUND

Aorto-cardiac fistulae are a rare but increasingly reported entity, and data are scarce.

METHOD

The authors performed a systematic review of ACFs to characterize the underlying etiology, clinical presentation, and compare outcomes of treatment strategies.

RESULTS

3,733 publications were identified in the search. Of those, 292 studies including 300 patients were included. Etiology of ACFs was 38% iatrogenic, 25% infectious, 14% traumatic, and 15% due to other causes. Most patients (74%) presented with heart failure. Common locations were aortic-right atrium (37%), and aortic-pulmonary artery (25%). The majority of patients (71%) were treated surgically, while 13% were treated percutaneously, and 16% were treated conservatively. Patients who were managed conservatively had a higher mortality than those treated with invasive closure (53% vs. 12% vs. 3%, p = <0.00001).

CONCLUSIONS

This systematic review sheds light on this highly morbid condition. Once recognized, fistula closure appears to be superior to conservative management.

Aorto-atrial fistula formation and therapy

Aorta-atrial fistulas (AAF) are a rare but complex pathological condition. These fistulas are characterised by aberrant blood flow between the aorta and either atrium. In the present manuscript, we present a comprehensive overview of the clinical characteristics, formation and treatment of this condition. A literature review was conducted using PubMed. Aorta-Atrial Fistula was used as the primary search term. The clinical presentation of AAF encompasses a wide range of signs and symptoms of heart failure including dyspnoea, chest pain, palpitations, fatigue, weakness coughing or oedema. Causes of fistulas can be congenital or acquired, whilst diagnosis is normally achieved via echocardiography or MRI. Due to the low incidence of AAF, no clinical trials have been performed in AAF patients and treatment strategies are based on expert opinion and consensus amongst the treating physicians. Uncorrected AAF may continue to impose a risk of progression to overt heart failure. The repair of an AAF can either be surgical or percutaneous. AAF is a relatively rare but very serious condition. Clinicians should consider the possibility of AAF, when a new continuous cardiac murmur occurs, especially in patients with a history of cardiac surgery or with signs of heart failure. Closure of the AAF fistula tract is generally recommended. Further studies are required to define optimal therapeutic strategies, but these are hindered by the rarity of the occurrence of this disorder.

Acquired aortocameral fistula occurring late after infective endocarditis: An emblematic case and review of 38 reported cases

AIM

To delineate the features and current therapeutic option of congenital and acquired aortocameral fistulas (ACF) secondary to iatrogenic or infectious disorders.

METHODS

From a PubMed search using the term "aortocameral fistula", 30 suitable papers for the current review were retrieved. Reviews, case series and case reports published in English were considered. Abstracts and reports from scientific meetings were not included. A total of 38 reviewed subjects were collected and analyzed. In addition, another case - an adult male who presented with ACF between commissures of the right and non-coronary sinuses and right atrium as a late complication of Staphylococcus aureus infective endocarditis of the AV - is added, the world literature is briefly reviewed.

RESULTS

A total of thirty-eight subjects producing 39 fistulas were reviewed, analyzed and stratified into either congenital (47%) or acquired (53%) according to their etiology. Of all subjects, 11% were asymptomatic and 89% were symptomatic with dyspnea (21 ×) as the most common presentation. Diagnosis was established by a multidiagnostic approach in 23 (60%), single method in 14 (37%) (echocardiography in 12 and catheterization in 2), and at autopsy in 2 (3%) of the subjects. Treatment options included percutaneous transcatheter closure in 12 (30%) with the deployment of the Amplatzer duct or septal occluder and Gianturco coil and surgical correction in 24 (63%).

CONCLUSION

Acquired ACF is an infrequent entity which may occur late after an episode of endocarditis of the native AV. The management of ACF is generally by surgical correction but non-surgical device intervention has recently been introduced as a safe alternative.