Cardiothoracic Surgery: Student/Resident Case Report Poster - Cardiac and Thoracic Surgery |

A Dangerous Connection: Aorto Atrial Fistula FREE TO VIEW

Ali Ghani, MD; Faizan Malik, MD; Irfan Ahsan, MD; Salman Farhat, MD; Wajahat HUmayun, MD; Ahsan Raza, MD
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Abington Jefferson Health, Horsham, PA

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):51A. doi:10.1016/j.chest.2016.08.058
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SESSION TITLE: Student/Resident Case Report Poster - Cardiac and Thoracic Surgery

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Sinus of Valsalva Aneurysm is extremely rare, 0.09%-0.15% of cases, and comprises up to 3.5% of congenital cardiac anomalies1. It usually presents once it is ruptured and symptoms range from mild shortness of breath to congestive heart failure2. Early recognition and immediate surgical intervention are keys to a successful outcome

CASE PRESENTATION: A 45-year-old woman with a past medical history of uterine sarcoma resection complicated by chronic right hydronephrosis and a chronic stent, a recent deep vein thrombosis and massive pulmonary embolism requiring surgical embolectomy and chronic anticoagulation, presented with increasing dyspnea on exertion and palpitations. Initial assessment including vital signs showed blood pressure of 132/80mmHg, heart rate 115 beats/min and respiratory rate of 18/min. Cardiovascular examination revealed absent jugular venous distension, a new pan-systolic non-radiating grade II/VI murmur at the mitral area, faint S1, S2 and bilateral clear breath sounds. An electrocardiogram revealed sinus tachycardia with no ischemic changes. An urgent transthoracic echocardiogram demonstrated a possible membranous ventricular septal defect. This warranted a trans-esophageal echocardiogram (TEE) which surprisingly revealed left to right shunt with systolic and diastolic flow between the right sinus of Valsalva and the right atrium. This was consistent with aorto-atrial fistula. She underwent emergent successful redo sternotomy and closure of the fistula with no postoperative complications.

DISCUSSION: Aorto-atrial fistula can be easily missed in the absence of infective endocarditis and typical examination findings. TEE should be used as a test of choice in case of suspicion and should be considered as a follow-up measure in high-risk patients. This case is very unique since it is the first case to report rupture of sinus of Valsalva aneurysm as a complication of pulmonary artery embolectomy. Prior studies have recommended that sinus of Valsalva aneurysm, ruptured or not, should be managed with early surgical repair to prevent serious complications or even death3

CONCLUSIONS: Aorto-atrial should always be suspected in cases of patients with new onset heart murmur and history of chest surgeries or persistent bacteremia and mycotic aneurysms. This case also reiterates the point of urgent investigation of a new heart murmur

Reference #1: Post M, Braam R, Groenemeijer B, Nicastia D, Rensing B, Schepens M. Rupture of right coronary sinus of Valsalva aneurysm into right ventricle. Netherlands Heart Journal 2010;18:209-11.

Reference #2: Reichert C. Ruptured sinus Valsalva aneurysm, a rare cause of heart failure. Netherlands Heart Journal 2008;16:60-1.

Reference #3: Moustafa S, Mookadam F, Cooper L, et al. Sinus of Valsalva aneurysms—47 years of a single center experience and systematic overview of published reports. The American journal of cardiology 2007;99:1159-64.

DISCLOSURE: The following authors have nothing to disclose: Ali Ghani, Faizan Malik, Irfan Ahsan, Salman Farhat, Wajahat HUmayun, Ahsan Raza

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