European Journal of Echocardiography 2003 4(3):221-222; doi:10.1016/S1525-2167(02)00138-5
© 2003 by European Society of Cardiology
Copyright © 2003, The European Society of Cardiology
Transoesophageal echocardiographic diagnosis of aortico-left atrial fistula in aortic valve endocarditis
A.M Esen,
M.S Küçüko
lu*,
B Ökçün,
Ö Batukan and
S Üner
The Institute of Cardiology, 
stanbul University, stanbul, Turkey
Received 7 June 2002; accepted after revision 25 September 2002.
* Address correspondence to: M. Serdar Küçükolu, FESC, 9 10 K
sm D 15 Blok D:15 Ataköy 34750, stanbul, Turkey. Tel: +90 532 2860797; Fax: +90 212 5294262. kucukoglu3{at}yahoo.com
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Abstract
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Intra-cardiac fistulas are rarely seen and they are estimated
to account for <1% of all cases of infective endocarditis.
Fistulization of paravalvular abscesses has been found in 6%
to 9% of cases. This is a report of an unusual communication
between the abscess region in the aortic root and the left atrium.
A 44-year-old patient diagnosed with infective endocarditis
had continuous fevers despite antibiotic therapy. Transoesophageal
echocardiography revealed multiple vegetations on aortic valve,
fistulization of an aortic root abscess to the left atrium and
mitral regurgitation and moderate aortic regurgitation. At surgery,
multiple vegetations on the aortic valve and a large abscess
cavity establishing direct communication between aortic root
and the left atrial cavity through a fistulous tract were discovered.
This experience demonstrates the improved sensitivity and specificity
of transoesophageal echocardiography in defining periannular
extension of infective endocarditis.
Keywords: transoesophageal echocardiography; infective endocarditis; fistula; aortic valve
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Introduction
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Periannular extension is common, occurring in 10% to 40% of
all native valve infective endocarditis and complicates aortic
valve endocarditis more commonly than mitral or tricuspid valve
endocarditis
[1]. However, intra-cardiac fistula formation is
seen less frequently and it is estimated to account for <1%
of all cases of infective endocarditis
[2]. Fistulization of
paravalvular abscesses has been found in 6% to 9% of cases
[3,4].
Transoesophageal echocardiography is an invaluable tool in diagnosis
of the paravalvular abscesses and fistulas complicating infective
endocarditis. This is a report of an unusual communication between
the abscess region in the aortic root and the left atrium.
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Case report
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A 44-year-old man was hospitalized with complaints of malaise,
loss of weight, fever and painful rashes on hands and feet.
On physical examination, his temperature was 39.2°C and
there were murmurs of aortic insufficiency and mitral regurgitation.
The erythrocyte sedimentation rate was 120 mm/h and other remarkable
laboratory findings were elevated C-reactive protein level (120
mg/dl), leukocytosis (17 600 mm
3) and anaemia (haemoglobin:
8.3 g/dl). Three sets of blood cultures grew
Streptococcus viridans.
The patient was then treated with vancomycin (1 g b.i.d) and
gentamicin (80 mg t.i.d) on being diagnosed with infective endocarditis.
However, when the patient continued having fevers despite antibiotic
therapy, multiplane transoesophageal echocardiography was performed
with the high suspicion of a complication. Transoesophageal
echocardiography revealed multiple vegetations on aortic valve,
fistulization of an aortic root abscess (
Figs 1 and 2
) to the
left atrium, which was not possible to visualize on the transthoracic
examination, and mild mitral regurgitation and moderate aortic
regurgitation. The abcess cavity was approximately 1.3 cm by
1.4 cm with two openings: one to the left atrium and one to
the aorta. The transfistula continuous wave Doppler tracing
confirmed the pressure difference between the aorta and the
left atrium (
Fig. 3).
At surgery performed 10 days later, multiple vegetations on
the aortic valve and a large abscess cavity covering the region
of non-coronary and right coronary cusps was seen. The abscess
cavity was cleaned and the fistulous openings on both the left
atrium and the aortic root were obliterated with sutures. The
aortic valve was replaced with a St. Jude prosthetic valve.
The patient remained afebrile and asymptomatic following operation
and he was continued on antibiotic therapy for the ensuing 6
weeks.
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Discussion
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Because of their rarity, intra-cardiac fistulas complicating
infective endocarditis are only reported as brief and single
cases in literature. The first case of posterior aortic root
abscess that ruptured into the left atrial cavity was reported
by Behnam in 1992
[5]. Anguera
et al.
[6] recently reported a
series of prospectively followed infective endocarditis cases
complicated with fistulas.
Our patient is unique among those cases in the sense that the route of the intra-cardiac communication is unusual. According to Anguera et al., the most common site of an aortic root abscess was the right coronary sinus of an aortic annulus. Also, their study showed that ruptured abscesses of the right sinus of Valsalva communicating with the right ventricle, the right atrium or both ventricles. The non-coronary sinus showed fistulization into the right atrium and intra-cardiac shunt through the membranous septum[6]. In our case, the unusual fistulization of the abscess overlying the non-coronary and the right coronary cusps into the left atrium was seen by transoesophageal echocardiography and then confirmed at surgery.
This experience once again proves the improved sensitivity and specificity of transoesophageal echocardiography in defining periannular extension of infective endocarditis and furthermore shows how meticulous search for these complications can reveal unusual routes of intra-cardiac communication.
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References
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- Bayer A.S., Bolger A.F., Taubert K.A., et al. Diagnosis and management of infective endocarditis and its complications. Circulation (1998) 98:2936–2948.[Free Full Text]
- Sexton D.J., Bashore T.M. Infective endocarditis. In: Comprehensive Cardiovascular Medicine—Topol E.J., ed. (1998) Lippincott-Raven. 637–667.
- Choussat R., Thomas D., Isnard R., et al. Perivalvular abscesses associated with endocarditis: clinical features and prognostic factors of overall survival in a series of 233 cases. Eur Heart J (1999) 20:232–241.[Abstract/Free Full Text]
- San Román J.A., Vilacosta I., Sarria C., et al. Clinical course, microbiologic profile and diagnosis of periannular complications in prosthetic valve endocarditis. Am J Cardiol (1999) 83:1075–1079.[CrossRef][Web of Science][Medline]
- Behnam R. Aortico-left atrial fistula in aortic valve endocarditis. Chest (1992) 102:1271–1273.[CrossRef][Web of Science][Medline]
- Anguera I., Quaglio G., Miro J.M., et al. Aortocardiac fistulas complicating infective endocarditis. Am J Cardiol (2001) 87:652–654.[CrossRef][Web of Science][Medline]
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Abstract
Introduction
