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| Year : 2014
| Volume
: 17 | Issue : 2 | Page
: 155-156 |
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| Aortic root to left-atrial fistula after aortic valve replacement: A rare complication and its intraoperative management |
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Tanveer Ahmad1, Satish Chithiraichelvan2, Thimmangouda Ayangouda Patil2, Vivek Jawali1
1 Department of Cardiothoracic Surgery, Fortis Hospitals, Bengaluru, Karnataka, India
2 Department of Cardiac Anaesthesia, Fortis Hospitals, Bengaluru, Karnataka, India
Click here for correspondence address and
email
| Date of Submission | 17-Oct-2013 |
| Date of Acceptance | 18-Feb-2014 |
| Date of Web Publication | 1-Apr-2014 |
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 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 2023 Jan 29];17:155-6. Available from: https://www.annals.in/text.asp?2014/17/2/155/129872 |
| Introduction | |  |
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 | | |
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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| Discussion | | |
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 | | |
| 1. | Stechert MM, Kellermeier JP. Aorto-atrial fistula: An important complication of aortic prosthetic valve endocarditis. Anesth Analg 2007;105:332-3. 
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| 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.
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| 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.
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| 4. | Ananthasubramaniam K. Clinical and echocardiographic features of aorto-atrial fistulas. Cardiovasc Ultrasound 2005;3:1.
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| 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.
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| 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.
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| 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.
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Correspondence Address:
Tanveer Ahmad
#156, 3rd Cross, Shirdi Sai Nagar, Dr. Shivaram Karanth Nagar, Bengaluru - 560 077, Karnataka
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0971-9784.129872
[Figure 1], [Figure 2], [Figure 3] |
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| This article has been cited by | | 1 |
Aorto-Left Atrial Fistula after Aortic Valve Replacement : a Rare Complication |
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| Tomonori Ochiai, Tetsuro Uchida, Yoshinori Kuroda, Atsushi Yamashita, Eiichi Ohba, Shingo Nakai, Kimihiro Kobayashi, Mitsuaki Sadahiro | | Japanese Journal of Cardiovascular Surgery. 2021; 50(1): 31 | | [Pubmed] | [DOI] | |
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