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Case 170

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A 31-year-old male patient comes to the ER after being stabbed in the third intercostal space. He was awake, alert and oriented, hemodynamically stable and had a thoracic drain. After ruling out the commitment of any other structure, he was discharged. After 2 months, was again admitted to the ER complaining of acute dyspnea, abdominal distension and pitting edema in lower limbs (++/4+). At the exam, he had a diastolic murmur at the accessory aortic area, with irradiation to the armpit, and palpable right ventricle (RV). Chest X-ray and echocardiogram showed increased pulmonary flow and RV overload, and then was submitted to cardiac catheterisation.

Based on the clinical picture and the images, which one of the following is the most likely diagnosis?

a) Acute aortic dissection

25%

b) Infective endocarditis and aortic valve lesion

25%

c) Aorta-right ventricle fistula and aortic lesion

25%

d) Ectatic aorta

25%
   

Video analysis

Left ventriculography (video 1) and aortography (video 2), left anterior view. Contractility preserved in both ventriculi. There are also no alterations on the aortic diameter and interventricular septum. Aortography shows massive reflux to the left ventricle.

Highlights

- Aorta-right ventricle fistulas are usually formed at the upper surface of the aorta, above coronary emergency and the right ventricle exit.

- The main causes are infective endocarditis, Valsalva sinus aneurysm, aortic dissection and trauma.

- Diagnosis is made after transthoracic or transesophagic echocardiogram and must be complemented with a cardiac catheterization or aortography.

- The continuous murmur in the precordial are is characteristic, but can only manifest later.

- The surgical treatment must be done after initial hemodynamical stabilization.

References

- Barbosa FM, Quiroga JM, Otero AE, Girela GA. Aorticvalveregurgitationwithaorto-right ventricular fistula followingpenetratingcardiacinjury. Interact CardioVascThoracSurg  2012 Aug;13 (6): 653-654.

- Samuel LE, Kaufman MS, Rodriguez-Veja J, Morris RJ, Brockman SK. Diagnosisand Management of TraumaticAorto–Right Ventricular Fistulas. Ann ThoracSurg 1998 Jan;65 (1): 288–92.

- Kaya A, Dekkers P, Loforte A, Jaarsma W, MorshuisWJ. Traumaticaorto-right ventricular fistula with aortic insufficiency. Ann ThoracSurg 2005 Dec;80 (6): 2362–4.  

- Theron JP, Theron HD, Long M, Marx JD. Late presentation of aorto–right ventricular fistula and associated aortic regurgitation following penetrating chest trauma. Cardiovasc J Afr 2009 Nov;20 (6): 357–359.

- Patel  V, Fountain  A, Guglin M, Nanda, NC. Three-Dimensional Transthoracic Echocardiography in Identification of Aorto-Right Atrial Fistula and Aorto-Right Ventricular Fistulas. Echocardiography2010 Oct;27 (9): E105–E108.

- Zipes DP, Libby P,Bonow RO, Braunwald E. Braunwald: Tratado de Doenças Cardiovasculares. 7ª Ed. São Paulo: Elsevier; 2006.

Author

Júlia Alvarenga Petrocchi, acadêmica do 10º período da Faculdade de Medicina da UFMG.

Email: juliapetrocchi[at]gmail.com

Supervisor

Dr. Bruno Ramos Nascimento, interventional cardiologista, member of the Cardiovascular Surgery and Cardiology Department – Hospital das Clinicas da UFMG, and professor of the Medicine Department of UFMG.

Email: ramosnas[at]gmail.com

Reviewers

Ana Júlia Bicalho, Bárbara Bragaglia, Ana Luiza Tavares, Luanna Monteiro, Júlio Guerra.

Translated by

Renato Gomes Campanati, 6th year medical student at UFMG. Email: campanati[at]ufmg.br

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