An Unusual Case of Aortic-Right Atrium Fistula: A Diagnostic and Therapeutic Challenge

Abstract

An aorta-to-right atrium (RA) fistula is an anomalous communication between the ascending or descending thoracic aorta and the RA. In this report, we describe a case of an idiopathic aortic root-to-RA fistula occasionally found during a coronary angiography performed in a young patient admitted for acute chest pain with evidence of multivessel coronary artery disease. The anatomical peculiarity of this fistulous communication is that it gave origin to collateral vessels furnishing the inferolateral wall of the left ventricle. The case represented a diagnostic and therapeutic challenge that required a multimodality imaging and a multidisciplinary team approach.

Keywords: Aorta-right atrium fistula; coronary artery disease; multimodality imaging.

Figure 1

Transthoracic echocardiography, apical 4 chamber view (a), 2 chamber view (b) and 3 chamber view (c), short-axis view at the level of aortic valve (d), short-axis view at the level of aortic valve with color Doppler (e) and short-axis view at the level of ascending aorta (f). Normal chamber dimensions and regular wall thickness can be observed

Figure 2

Urgent angiography that demonstrated critical lesion of mid-distal anterior descending artery, occlusion of distal apical recurrent anterior descending artery, and thrombotic subocclusion of a first proximal obtuse marginal, as culprit lesion (a and b); occlusion of the right coronary artery at the proximal segment (c). Angiographic result after percutaneous coronary intervention of culprit lesion (d)

Figure 3

Coronary angiography (a and b), at selective injection, showing a huge fistulous communication between right Valsalva coronary sinus and the right atrium, with several collateral vessels emerging from the fistula and oriented toward posterolateral wall of the left ventricle. Angio-computed tomography (c and d) showing the fistolouse comunication between ascending aorta and right atrium

Figure 4

Angiographic result after percutaneous coronary intervention of left main and anterior descending artery (a and b) confirmed with intravascular ultrasound pullback that demonstrated correct sizing and good expansion of drug-eluting stents in left main (c), proximal anterior descending artery (d), and of overlapping bioabsorbable vascular scaffolds implanted in mid anterior descending artery (e)