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Asymptomatic Aorto-atrial Fistula Identified With Intraoperative Transesophageal Echocardiography

2012; Elsevier BV; Volume: 26; Issue: 6 Linguagem: Inglês

10.1053/j.jvca.2012.06.028

1532-8422

Stefaan Bouchez, Patrick Wouters, Guy Vandenplas,

Congenital Heart Disease Studies

With great interest, we read the report of Takahashi et al1Takahashi M. Wohler A. Abboud J. et al.Intraoperative imaging and off-pump ligation of coronary artery fistula.J Cardiothorac Vasc Anesth. 2012; ([Epub ahead of print])Google Scholar titled "Intraoperative Imaging and Off-Pump Ligation of Coronary Artery Fistula." The management of coronary artery fistula (CAF) is indeed somewhat controversial, especially in younger, asymptomatic patients. It generally is agreed that symptomatic lesions and larger fistulae with significant shunting should be treated. Surgical ligation2Bouchez S. Coddens J. Vanermen H. et al.Multiplane transesophageal echocardiography in minimally invasive surgery for coronary artery fistula.J Cardiothorac Vasc Anesth. 2001; 15: 114-117Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar generally is accepted as the treatment of choice in CAF. An aorto-atrial fistula (AAF) is a fistulous vascular extracardiac communication that may present as an incidental finding or with heart failure or pulmonary edema. An AAF can originate from any of the 3 sinuses of Valsalva, but origin from the noncoronary sinus is extremely rare.3Chandra S. Vijay S. Kaur D. et al.Congenital aorta right atrial fistula: Successful transcatheter closure with the Amplatzer occluder.Pediatr Cardiol. 2011; 32: 1057-1059Crossref PubMed Scopus (14) Google Scholar Although an AAF most commonly originates from the ascending aorta, it may emanate from the descending thoracic aorta.4Nihoyannopoulos P. Sapsford R. Oakley C.M. Congenital fistula between the aorta and left atrium.Br Heart J. 1987; 57: 387-390Crossref PubMed Scopus (15) Google Scholar An acquired AAF, which may be more common than a congenital AAF, may be associated with prosthetic valve endocarditis after root repair and transcatheter closure of septal defects.5Darwazah A. Kiswani M. Ismail H. et al.Aorto-right atrial fistula: A complication of prosthetic aortic valve endocarditis A case report.J Heart Valve Dis. 2006; 15: 142-145PubMed Google Scholar, 6Schwartzbard A. Tunick P.A. Kronzon I. Images in cardiovascular medicine Aorta-to-left atrium fistula: A complication of endocarditis.Circulation. 1998; 98: 604Crossref PubMed Scopus (3) Google Scholar A rare case of AAF has been reported after internal jugular vein catheterization.7Danenberg H.D. Hasin Y. Milgalter E. et al.Aorto-atrial fistula following internal jugular vein catheterization.Eur Heart J. 1995; 16: 279-281PubMed Google Scholar A congenital AAF is extremely rare, and a literature review did not show any report of a congenital AAF diagnosed in an adult patient. Commonly described associated cardiac anomalies with an AAF include a secundum type of atrial septal defect and persistence of the left superior vena cava.8Gajjar T. Voleti C. Matta R. et al.Aorta-right atrial tunnel: Clinical presentation, diagnostic criteria, and surgical options.J Thorac Cardiovasc Surg. 2005; 130: 1287-1292Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar Most patients with an AAF may be asymptomatic, but a patient can have mild symptoms (eg, palpitations, dyspnea on exertion, or recurrent respiratory tract infections) or major symptoms (ie, acute chest pain because of an AAF rupture associated with aortic dissection or heart failure associated with endocarditis or a ruptured aortic sinus). The presentation of an AAF may depend on the fistula size and the pressure and flow difference between communicating structures. The presence or development of symptoms mandates fistula closure. Echocardiography is the cornerstone for the diagnosis of an AAF because physical and clinical features of this condition may be absent or misleading.9Ananthasubramaniam K. Clinical and echocardiographic features of aorto-atrial fistulas.Cardiovasc Ultrasound. 2005; 3: 1Crossref PubMed Scopus (38) Google Scholar With 3-dimensional (3D) imaging, the correct anatomic and physiologic information may be obtained, which previously was not visible with 2-dimensional (2D) technology.10Fischer G.W. Salgo I.S. Adams D.H. Real-time three-dimensional transesophageal echocardiography: The matrix revolution.J Cardiothorac Vasc Anesth. 2008; 22: 904-912Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar Echocardiography with 3D imaging enables spatial orientation and visualization of the AAF and its relation to adjacent structures, which are important because of the potential complexity of the AAF and the presence of multiple anatomic variants.3Chandra S. Vijay S. Kaur D. et al.Congenital aorta right atrial fistula: Successful transcatheter closure with the Amplatzer occluder.Pediatr Cardiol. 2011; 32: 1057-1059Crossref PubMed Scopus (14) Google Scholar, 10Fischer G.W. Salgo I.S. Adams D.H. Real-time three-dimensional transesophageal echocardiography: The matrix revolution.J Cardiothorac Vasc Anesth. 2008; 22: 904-912Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar We recently evaluated a patient who had an asymptomatic AAF identified with transesophageal echocardiography (TEE) during cardiac surgery. A 61-year-old white man with critical 3-vessel coronary artery disease and normal left ventricular function was scheduled for coronary revascularization. During cardiac surgery, comprehensive TEE (Philips IE33; Philips Medical Systems, Andover, MA) was performed. With 2D color-flow Doppler in the midesophageal aortic valve short-axis view,11Shanewise J.S. Cheung A.T. Aronson S. et al.ASE/SCA guidelines for performing a comprehensive intraoperative multiplane transesophageal echocardiography examination: Recommendations of the American Society of Echocardiography council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in perioperative transesophageal echocardiography.J Am Soc Echocardiogr. 1999; 12: 884-900Abstract Full Text Full Text PDF PubMed Scopus (290) Google Scholar a color-flow jet was noted at the orifice of the left atrial appendage (Fig 1A). Additional 3D TEE with flow mapping showed a colorful fountain at the base of the left atrial appendage that originated from the left coronary aortic sinus (Fig 1B). The origin of the AAF close to the mainstem of the left coronary artery was visualized on the 3D image with the cropping tools of the 3D software (QLAB; Philips Ultrasound, Andover, MA) (Fig 1C). The left atrial drainage opening of the AAF was detected on the left atrial 3D view (Fig 1D). The trajectory of the AAF was shown on the 2D image, which was extracted from the 3D data (Fig 2).Fig 2The trajectory of the AAF (arrow) from the aorta to the left atrial appendage was visualized on the 2D color Doppler view extracted from the 3D color-flow data.View Large Image Figure ViewerDownload Hi-res image Download (PPT) On visual inspection of the lateral side of the heart, the atrioventricular groove, and the left atrial appendage did not show a substantial fistula or any other pathologic or inflammatory process. The decision was made to leave the AAF untouched because the flow through the AAF was minimal with no apparent hemodynamic contribution, and there was no left atrial enlargement. Triple coronary artery bypass surgery was performed, and the perioperative course was uneventful. The patient left the hospital after 7 days in excellent clinical condition. In this patient, the diagnosis of the asymptomatic AAF was made by routine intraoperative 2D TEE with color Doppler imaging, which showed an aberrant flow jet from the aorta to the left atrium. The addition of 3D TEE improved the demonstration of the anatomic course and size of the AAF. The AAF had not been observed in preoperative coronary angiography because of the small size and limited hemodynamic effect. The AAF caused no clinical effect or change in surgical plan in this patient. However, this case shows the value of intraoperative TEE as an integral part of the morphologic and functional assessment during cardiac surgery. This type of AAF may be better delineated with TEE than transthoracic echocardiography because an AAF to the left atrium usually occurs on the posterior side of the aorta.9Ananthasubramaniam K. Clinical and echocardiographic features of aorto-atrial fistulas.Cardiovasc Ultrasound. 2005; 3: 1Crossref PubMed Scopus (38) Google Scholar This case shows the limitation of viewing a 3D structure, such as the heart with 2D imaging, and the improved imaging achievable with 3D echocardiography. Therefore, intraoperative imaging with 3D echocardiography may be useful to improve the identification of potentially important lesions on the surgical course and clinical outcome.10Fischer G.W. Salgo I.S. Adams D.H. Real-time three-dimensional transesophageal echocardiography: The matrix revolution.J Cardiothorac Vasc Anesth. 2008; 22: 904-912Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar, 12Patel V. Fountain A. Guglin M. et al.Three-dimensional transthoracic echocardiography in identification of aorto-right atrial fistula and aorto-right ventricular fistulas.Echocardiography. 2010; 27: E105-E108Crossref PubMed Scopus (13) Google Scholar Intraoperative Imaging and Off-Pump Ligation of Coronary Artery FistulaJournal of Cardiothoracic and Vascular AnesthesiaVol. 26Issue 5PreviewCoronary arterial fistulae (CAFs) are rare congenital anomalies that were described first by Krause in 1865.1 CAFs may be complicated by myocardial ischemia, intracardiac shunting, endocarditis, or aneurysm formation.2 Therefore, patients often are referred for surgical correction. Intraoperatively, because of the tortuosity and aneurysmal dilation, it can be difficult to identify the origin and termination of the CAFs.3,4 The fistulae may terminate in a right-sided cardiac chamber, systemic vein, or the pulmonary artery (PA). Full-Text PDF