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Critical Care |

Aorto-Left Atrial Fistula

Muhammad Adrish, MD; Deborah Orsi, MD
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Montefiore Medical Center, The University Hospital for Albert Einstein College of Medicine, Bronx, NY


Chest. 2014;146(4_MeetingAbstracts):317A. doi:10.1378/chest.1975813
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Abstract

SESSION TITLE: Critical Care Student/Resident Case Report Posters III

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Aorto-atrial fistula is a rare but devastating complication of aortic valve endocarditis. We report a case of 58 year old woman who presented with altered mentation and lower extremity weakness. Detailed evaluation revealed bilateral embolic strokes, aortic valve endocarditis, severe aortic regurgitation and aorto-left atrial fistula. She subsequently underwent successful surgical repair.

CASE PRESENTATION: A 58 year old female with hypertension and diabetes mellitus was admitted with twelve hours of lower extremity weakness and confusion. Initial evaluations revealed acute renal failure, new-onset atrial fibrillation and pulmonary edema. Computed tomography and magnetic resonance imaging of the brain showed bilateral acute and subacute embolic infarcts. Blood cultures grew beta streptococcus group B and antibiotic therapy was initiated. Transesophageal echocardiography demonstrated large mobile vegetations on the aortic valve leaflets, severe aortic regurgitation, and a fistula between the aortic root and left atrium. The patient required immediate cardiac surgery. Intra-operative findings included fungating vegetations invading the aortic valve leaflets and annulus, an aorto-left atrial fistula, mitral valve leaflet vegetations, a tricuspid valve abscess, and thrombus of the left atrial appendage. An extensive operative repair included: aortic root replacement with a homograft patch repair of the right and left atria, septal leaflet of the tricuspid valve, reconstruction of the aorto-mitral curtain, and left atrial appendage ligation. After recovering from post-operative cardiogenic shock, she was successfully extubated, and ultimately had a favorable outcome.

DISCUSSION: Infective endocarditis is an infection of the endocardial surface of the heart and can involve cardiac valves, the mural endocardium, or a septal defect. Acute native valve endocarditis typically involves normal valves and usually has an aggressive course. Staphylococcus aureus and group B streptococci are the usual causative agents of this type of endocarditis. Major complications include valvular insufficiency, congestive heart failure, embolic episodes, sinus of valsalva aneurysm and intra-cardiac fistulas. Treatment is focused at eradication of infectious agent, addressing valvular complications and treatment of underlying congestive heart failure. Approximately 15-25% patients require surgery for indications such as refractory heart failure, persistent sepsis after 72 hours of appropriate antibiotic treatment, conduction abnormalities, rupture of aneurysm of sinus of valsalva or fungal endocarditis.

CONCLUSIONS: An aorto-atrial fistula is an extremely rare but devastating complication of endocarditis that requires immediate attention and repair.

Reference #1: Archer TP, Mabee SW, Baker PB, Orsinelli DA, Leier CV. Aorto-left atrial fistula. A reversible cause of acute refractory heart failure. Chest. 1997 Mar;111(3):828-31.

DISCLOSURE: The following authors have nothing to disclose: Muhammad Adrish, Deborah Orsi

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