Aorto-right artrial fistula: a rare complication of aortic dissection

Abstract

We describe the successful surgical repair of an acute aortic dissection that had caused an aorto-right atrial fistula in a 67-year-old man. The patient was admitted to the hospital on an emergency basis because of severe heart failure. The diagnosis of acute aortic dissection with rupture into the right atrium was confirmed by use of intraoperative transesophageal echocardiography, although rupture of a sinus of Valsalva aneurysm into the right atrium had been suggested initially by 2-dimensional and Doppler transthoracic echocardiography. At surgery, we found the patient to have aortic arch dissection with complete separation of the right coronary artery from the sinus of Valsalva and a false lumen that had ruptured into the right atrium. The aortic arch was repaired directly. The ascending aorta was successfully replaced with a composite graft. Aortic dissection with rupture into the right atrium is extremely rare and leads to death rapidly. As shown in this case, such a condition might be mistaken for an aneurysmal rupture of the sinus of Valsalva, with use of transthoracic echocardiography alone. Transesophageal echocardiography is a useful noninvasive method to further define or confirm the diagnosis. Early surgical intervention is necessary in patients with this condition to prevent profound shock and end-organ failure.

Fig. 1 Transthoracic echocardiography: A) 2-dimensional parasternal short-axis view showing the fistula between the aortic root and the right atrium, and B) pulsed Doppler study showing continuous flow through the fistula. A = Aorto–right atrial fistula; LA = left atrium; RA = right atrium; RVOT = right ventricular outflow tract; AA = aortic aneurysm

Fig. 2 Drawing shows the aortic dissection found at operation. A = intimal tear over aortic arch; B = right coronary artery disruption; C = aorto–right atrial fistula; FL = false lumen; RA = right atrium; TL = true lumen