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Mapping the pathway: understanding an aorto-atrial fistula in a patient with heart failure
Session:
CASOS CLÍNICOS DE INSUFICIÊNCIA CARDÍACA E CUIDADOS INTENSIVOS
Speaker:
Rita Almeida Carvalho
Congress:
CPC 2025
Topic:
E. Coronary Artery Disease, Acute Coronary Syndromes, Acute Cardiac Care
Theme:
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Subtheme:
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Session Type:
Sessão de Casos Clínicos
FP Number:
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Authors:
Rita Almeida Carvalho; Débora Sá; Catarina Pohle; Pedro Magro; António Ferreira; Regina Ribeiras; Marisa Trabulo; Miguel Mendes
Abstract
<p style="text-align:justify"><span style="font-size:16px"><span style="font-family:Arial,Helvetica,sans-serif"><strong>[Patient presentation]:</strong></span></span></p> <p style="text-align:justify"><span style="font-size:16px"><span style="font-family:Arial,Helvetica,sans-serif">A 37-year-old man presented to the Cardiology Unit with worsening breathlessness, peripheral edema, and weight gain over four months. A year earlier, he underwent bariatric surgery for obesity with uneventful postoperative recovery. Preoperative cardiac assessment was unremarkable. Recently, he had been initiated on high-dose diuretic therapy (furosemide 120 mg daily). On examination, the patient exhibited mild tachypnea, a continuous systolic-accentuated murmur, jugular vein distention, lower limb edema, and ascites. </span></span></p> <p style="text-align:justify"><span style="font-size:16px"><span style="font-family:Arial,Helvetica,sans-serif"><strong>[Initial work up]:</strong></span></span></p> <p style="text-align:justify"><span style="font-size:16px"><span style="font-family:Arial,Helvetica,sans-serif">Laboratory analysis showed elevated NT-proBNP (4852 pg/mL). Electrocardiography revealed sinus rhythm with biphasic P waves, occasional premature ventricular contractions, and poor R wave progression. Transthoracic echocardiography identified an aorto-atrial fistula between the non-coronary sinus of Valsalva (NC SV) and the right atrium (RA), right heart overload, and an estimated pulmonary artery systolic pressure of 51 mmHg. A separate interatrial septal defect (ASD) with left-to-right shunting was also noted.</span></span></p> <p style="text-align:justify"><span style="font-size:16px"><span style="font-family:Arial,Helvetica,sans-serif">Multimodal imaging via 3D transesophageal echocardiography fused with cardiac computed tomography (CT) confirmed a rupture of the NC SV with a shunt to the RA, positioned above the plane of the tricuspid valve. The aortic-to-RA jet exhibited a parallel trajectory to the plane of the tricuspid valve, assuming an eccentric direction with a Coanda effect along the lateral wall of the RA. Despite lacking typical aneurysmatic features, the NC SV displayed a globular morphology, and the fistulous pathway appeared thick and echo-dense, indicative of chronicity and raising suspicion of congenital origin. Furthermore, the interatrial septum exhibited a discontinuity consistent with an ostium secundum ASD with a larger diameter of 16mm, resulting in a significant left-to-right shunt by color Doppler evaluation. </span></span></p> <p style="text-align:justify"><span style="font-size:16px"><span style="font-family:Arial,Helvetica,sans-serif"><strong>[Diagnosis and Management]: </strong></span></span></p> <p style="text-align:justify"><span style="font-size:16px"><span style="font-family:Arial,Helvetica,sans-serif">The diagnosis of right heart failure secondary to an aorto-atrial fistula was established. There were no signs of associated aneurysm, infection, trauma, or endocarditis. Surgical repair involved median sternotomy and cardiopulmonary bypass. A wide secundum ASD and a smaller tunnel-shaped defect near the tricuspid valve were closed. Inspection revealed the fistula exit in the NC SV without evidence of infection or trauma. Intraoperative echocardiography confirmed complete correction. Recovery was uneventful, and the patient was discharged four days post-surgery.</span></span></p> <p style="text-align:justify"><span style="font-size:16px"><span style="font-family:Arial,Helvetica,sans-serif"><strong>[Conclusion]: </strong></span></span></p> <p style="text-align:justify"><span style="font-size:16px"><span style="font-family:Arial,Helvetica,sans-serif">We describe an exceptionally rare case of a young patient admitted with subacute heart failure, due to an aorto-atrial fistula and ASD, in the absence of other associated conditions. Multimodal imaging using echocardiography and cardiac CT is crucial to identify and precisely characterize the fistulous path in order to accurately plan surgical intervention. </span></span></p>
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