Clinical and echocardiographic features of aorto-atrial fistulas

A 66 year old male with history of rheumatic heart disease and aortic valve replacement (AVR) (twice for severe native and subsequent prosthetic valve regurgitation) presented with progressive worsening fatigue, exertional dyspnea and paroxysmal nocturnal dyspnea. His other medical problems included poorly controlled hypertension and hyperlipidemia. Following his second AVR 4 years prior to this presentation, a routine follow-up 2-dimensional echocardiogram (TTE) had shown preserved left ventricular and prosthetic valve function and a aorto-atrial fistula with color flow between the aorta-and the left atrium. Notably, only a soft and short ejection murmur across the mechanical prosthesis was appreciated and no continuous murmurs were heard. This was felt to be a possible postoperative complication currently not of clinical significance given his asymptomatic status and he was treated medically and did well for the last 3–4 years.Physical examination during this visit revealed an afebrile patient with a blood pressure of 138/84 mm Hg, regular pulse of 84/minute. An ejection systolic murmur (2/6 in intensity) was heard all over the precordium likely from the flow across his prosthesis. No continuous murmurs were heard. No evidence for clinical heart failure, anemia, jaundice or infection was noted. Laboratory tests revealed no leukocytosis and blood cultures were negative. Given prior echo documentation of fistula and new symptomatology suggestive of heart failure, a transesophageal echocardiography (TEE) was requested for more detailed assessment of prosthesis and AAF. TEE revealed normal left ventricular function, normal aortic prosthesis function with trivial aortic regurgitation. An echolucent area above the mechanical prosthesis, close to the left atrium near the orifice of the left coronary artery was noted. There appeared to be expansion of a portion of this lucency into the left atrium during systole suggesting communication with the aorta (Fig 1) with turbule