European Journal of Echocardiography Advance Access originally published online on March 27, 2008
European Journal of Echocardiography 2008 9(3):419-421; doi:10.1093/ejechocard/jen025
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Aorta-atrial fistula, a rare complication of prosthetic valve endocarditis
Department of Cardiology, Sint Antonius Hospital Nieuwegein, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
Received 20 November 2007; accepted after revision 4 December 2007; online publish-ahead-of-print 27 March 2008.
* Corresponding author. Tel: +31 6099111; fax: +31 6092274. E-mail address: willemdewilde{at}yahoo.com
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A 51-year-old male with a history of a mechanical Carbomedics aortic and mitral valve replacement in 2003 and several re-operations because of endocarditis of the mitral valve in 2007 presented with heart failure 68 days after operation. Echocardiography confirmed the presence of a fistulous connection between the aorta and the left atrium. Because of the multiple surgical interventions and high operative risk, an initial conservative medical treatment was initiated and the clinical course was uneventful to this date.
Keywords: Heart failure; Aortic fistula; Aorto-atrial fistula; Endocarditis; Prosthetic heart valve
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A 51-year-old patient with a medical history of rheumatic valvular disease, atrial fibrillation, alcohol abuse, and combined aortic and mitral valve replacement (Carbomedics 25 mm and Carbomedics 31 mm, respectively) 4 years earlier was admitted 2 days after the onset of high fever. Physical examination demonstrated a sick and disorientated patient with blood pressure 145/100 mmHg, irregular pulse 110 bpm, high fever (39.9°C), and a slightly elevated central venous pressure. Multiple skin petechiae and splinter haemorrhages in the nail bed were noted, and auscultation was unremarkable. Clinical neurological examination revealed a right-arm paresis and dysarthria. Additional ophthalmologic investigation showed multiple exsudative haemorrhagic lesions of the retina, the so-called Roth's spots (Figures 1 and 2).
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Electrocardiography showed atrial fibrillation 109 bpm, multiple ventricular extra systoles, and diffuse non-specific repolarization disorders. Chest X-ray revealed no abnormalities. Serologic testing demonstrated elevated levels of C-reactive protein [maximal 218 mg/L (normal 0–10)], lactate dehydrogenase [1325 U/L (normal <220)], Troponin T [3.2 µg/L (normal <0.015)], and creatinine kinase [1803 U/L (normal <175)] with severe renal insufficiency [creatinine 439 µmol/L (normal <120 µmol/L)]. Multiple vegetations on the atrial side of the mechanical mitral valve were depicted by transthoracic and transoesophageal echocardiography.
Thus, diagnosis of prosthetic valve endocarditis was made. A combination of flucloxacillin and gentamycin was initiated, and patient was operated on the same day using a prosthetic mitral valve (Carpentier Edwards, 31 mm). A large vegetation on the present mitral prosthetic valve was confirmed.
On Day 2, blood cultures revealed Group G Haemolytic Streptococci and therefore antibiotic therapy was switched to amoxicillin and gentamycin. A CT-scan of the brain depicted two small cerebral foci. Because of anuria with a creatinine level of 735 µmol/L, continuous venovenous hemofiltration was initiated. On Day 5, the patient was haemodynamically unstable despite the use of inotropics. Control transoesophageal echocardiography demonstrated a massive paravalvular leakage. Therefore, patient was re-operated on. The post-operative stay was complicated with tamponade and persistent bleeding and therefore the patient was re-operated on another three times on Day 9. On Day 13, antibiotics were switched to the combination vancomycin and gentamicin because of mediastinal infection due to enterococcus faecalis. Eventually, the patient was discharged on Day 48 in good clinical condition. His renal and neurological functions had recuperated well.
Unfortunately, patient was re-admitted to the hospital on Day 68 with clinical signs of heart failure. A new holosystolic murmur was heard and serology showed anaemia [Hb, 5.0 mmol/L (normal 7.8–10.2)] and a mildly elevated level of lactate dehydrogenase (640 U/L). Repeated transoesophageal echocardiography demonstrated a fistulous connection between the left atrium and aorta. Because of the relative stable condition of the patient, the multiple infectious complications and re-operations, the risk for an immediate re-operation was judged too high and the decision was made for an initial conservative medical treatment of the aorto-atrial fistula. The patient was treated with diuretics and blood transfusion and the initial follow-up until now (Day 180) is uneventful.
The development of an aortocavitary fistula in endocarditis is rare. The "European Aortocavitary fistula in endocarditis working group" reports an incidence of 1.6%1 with a very high mortality. Our decision to postpone eventual surgery because of high risk was supported by the document of the working group: ‘The relative benefits of surgical repair in patients with aortocavitary fistula must be weighed against the risk of complex reconstructive surgical techniques. Small fistulae may have little effect on haemodynamics. In selected cases with very high surgical risk and when the extent of intra-cardiac shunt appears to be low, conservative management may be contemplated’.1
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TopAbstractCase reportReference |
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- Anguera I, Miro JM, Vilacosta I, Almirante B, Anguita M, Munoz P, et al. Aorto-cavitary Fistula in Endocarditis Working Group. Aorto-cavitary fistulous tract formation in infective endocarditis: clinical and echocardiographic features of 76 cases and risk factors for mortality. Eur Heart J (2005) 26:288–97.
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