Congenital fistulous tract between aorta and right atrium presenting as heart failure in a newborn

Descending aorta to right atrial fistula: Transcatheter embolization of a very rare anomaly with coils

Key Clinical Message

Descending aorta to right atrial (RA) fistula is a rare and distinct clinical entity mimicking patent ductus arteriosus (PDA) and it may lead to rapid development of pulmonary vascular disease. Correct diagnosis and treatment, especially in the presence of other congenital heart defects, is very important. Interventional management is the treatment of choice.

Abstract

We present a case report of a trisomy 21 infant with atrial and ventricular septal defects and small patent ductus arteriosus (PDA) complicated by the presence of descending aorta to right atrial (RA) fistula with large left to right shunt leading to rapid increase in pulmonary vascular resistance. Transcatheter occlusion of the fistula followed by closure of the PDA with Nit-Occlud coil systems led to decreased pulmonary pressure and resistance permitting successful surgical repair of the patient's intracardiac defects with good outcome over 3 years of follow-up. Descending aorta to RA fistula is a rare and distinct clinical entity mimicking PDA and its correct diagnosis and treatment, especially in the presence of other congenital heart defects, is very important as it may lead to rapid development of pulmonary vascular disease.

[A rare cause of acute heart failure? : Aorto-right atrial fistula!]

BACKGROUND

Acute heart failure with symptoms such as dyspnea and edema has various causes. In rare cases cardiac fistulas can cause acute heart failure. Herein we present a case of subacute heart failure due to an acquired fistula between the aorta and right atrium.

CASE REPORT

A 48-year-old male was referred to the emergency room with increasing dyspnea on exercise and pitting edema of the lower extremities starting approximately 4 weeks previously. Echocardiographic workup showed an aorta-to-right atrium fistula. The patient was referred to a cardiothoracic surgery center for closure of the fistula.

Congenital Aorto-Cardiac Connections (CACC) Revisited: Introduction of a Novel Anatomic-therapeutic Classification

Abnormal congenital aorto-cardiac communications (CACC) are a heterogeneous constellation of anomalies that provide an abnormal connection between the aorta and other cardiac chambers or structures, including the atria, ventricles, the main pulmonary artery, and the coronary sinus. The current terminology of CACC has significant errors and shortcomings including inconsistent and interchangeable use of terms of fistula and tunnel and lack of an inclusive classification with practical information on therapeutic management. The aims of this study were threefold: firstly, to perform a concise narrative review of congenital pathologic connections between the aortic root and cardiac chambers which include rupture of congenital sinus of Valsalva aneurysm, aorto-left ventricular and less commonly right ventricular tunnels, coronary cameral fistulas, and aorto-atrial communications; secondly, to investigate the differentiating features of the so-called aorta right atrial tunnel (ARAT), with and without coronary artery take-off from the tunnel, and coronary cameral fistula (CCF) by applying a differential diagnostic assistance toolbox to two groups of patients with ARAT and CCF; and lastly, to propose a practical and inclusive anatomic-therapeutic classification for CACCs. The two main cornerstones of the proposed classification are the type of the connector between the aorta and cardiac chamber (hole versus passage) and the nature of the connecting passage ( anatomic versus extra-anatomic). We classified CACCs into three types. Depending on the intramural versus extramural course of the extra-anatomic connecting passage, type 3 is further subdivided into type 3A and type 3B.

Aorto-atrial fistula formation and therapy

Aorta-atrial fistulas (AAF) are a rare but complex pathological condition. These fistulas are characterised by aberrant blood flow between the aorta and either atrium. In the present manuscript, we present a comprehensive overview of the clinical characteristics, formation and treatment of this condition. A literature review was conducted using PubMed. Aorta-Atrial Fistula was used as the primary search term. The clinical presentation of AAF encompasses a wide range of signs and symptoms of heart failure including dyspnoea, chest pain, palpitations, fatigue, weakness coughing or oedema. Causes of fistulas can be congenital or acquired, whilst diagnosis is normally achieved via echocardiography or MRI. Due to the low incidence of AAF, no clinical trials have been performed in AAF patients and treatment strategies are based on expert opinion and consensus amongst the treating physicians. Uncorrected AAF may continue to impose a risk of progression to overt heart failure. The repair of an AAF can either be surgical or percutaneous. AAF is a relatively rare but very serious condition. Clinicians should consider the possibility of AAF, when a new continuous cardiac murmur occurs, especially in patients with a history of cardiac surgery or with signs of heart failure. Closure of the AAF fistula tract is generally recommended. Further studies are required to define optimal therapeutic strategies, but these are hindered by the rarity of the occurrence of this disorder.

Descending aorta to right atrial fistula

Here, we report a four-day old neonate presenting with cardiovascular collapse secondary to a descending aorta to right atrial fistula. Echocardiography was suggestive of the diagnosis and confirmed with computed tomographic (CT) imaging. The fistula was successfully occluded via cardiac catheterization using an Amplatzer Vascular Plug II implanted from the right atrial aspect. This report includes the first CT imaging of this extremely rare congenital defect as well as detailing the first successful transcatheter occlusion of this particular lesion.

Aorto-right atrial tunnel: fetal heart failure, diagnosis, and treatment

Aorto-right atrial tunnel (ARAT) is a rare clinical entity. Although it is a benign finding in most cases; it can present with significant right ventricular volume overload and congestive heart failure. This report describes the first fetal diagnosis of congenital aorto-right atrial tunnel and successful management of the heart failure by surgical intervention.

Transcatheter closure of aortico right atrial tunnel--a rare cardiac anomaly

Aortico right atrial tunnel is a rare anomaly with intriguing embryological basis characterized by a tubular communication between the ascending aorta and the right atrium. Few isolated cases reported in literature were often surgically managed on cardiopulmonary bypass. We report a successful transcatheter closure of a large aortico right atrial tunnel in 1 patient with anatomical and technical details.

A congenital fistula between the descending aorta and the right pulmonary vein in a neonate presenting with heart failure

We report a large congenital fistula connecting the descending thoracic aorta to the right upper pulmonary vein in a newborn baby presenting on the seventh day of life with cardiac failure and a continuous murmur heard posteriorly. The fistula was detected echocardiographically, and shown at cardiac catheterisation not to be suitable for percutaneous occlusion. The anatomy of the fistula was confirmed at surgery, when it was ligated successfully.

Aorto-right atrial fistula

We report a child in whom a fistula connected the descending thoracic aorta to the right atrium. This is a previously unreported cardiac malformation. The patient was initially misdiagnosed as having a patent ductus arteriosus (PDA). On clinical examination and auscultation, the problem was different from PDA in that the continuous machinery murmur was better heard on the right parasternal area and posteriorly on the left. Surgical ligation of the fistula through a left thoracotomy abolished the murmur.