An Occult Aortocavitary Fistula Presenting as Apparent Tricuspid Valve and Aortic Valve Endocarditis

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Infective endocarditis complicated by an occult aortocavitary fistula (n=1). Intervention: Transesophageal echocardiography-guided surgical aortic root replacement, right atrial debridement, pericardial patch fistula repair, and intravenous ceftriaxone vs. Transthoracic echocardiography (for diagnostic comparison). Primary outcome: Diagnosis and surgical resolution of occult aortocavitary fistula.

Q: What does this research mean for the field?

Transesophageal echocardiography is superior to transthoracic echocardiography for detecting infective endocarditis and periannular complications such as aortocavitary fistula. Novelty: ClaimNovelty.CONFIRMATORY. Consensus alignment: ConsensusAlignment.NEUTRAL.

Thong Nguyen; Mousumi M. Andersen; Rohesh J. Fernando; Karl M. Richardson

doi:10.1016/j.case.2018.09.003

October 29, 2018CASEOpen Access

An Occult Aortocavitary Fistula Presenting as Apparent Tricuspid Valve and Aortic Valve Endocarditis

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Why the study?

Aortocavitary fistula is a rare but potentially lethal perivalvular complication of infective endocarditis, particularly in patients with a bicuspid aortic valve, that can be difficult to detect on transthoracic echocardiography.

Key Points

To describe the clinical presentation, diagnostic challenges, and imaging considerations in identifying an occult aortocavitary fistula resulting from infective endocarditis.
Evaluated a 70-year-old woman with a known bicuspid aortic valve presenting with fever (102.9°F), bacteremia, leukocytosis (21 × 10^9/L), and acute respiratory arrest.
Performed initial transthoracic echocardiography (TTE) followed by urgent transesophageal echocardiography (TEE) to investigate unexplained hemodynamic compromise and multi-valvular involvement.
Initial TTE demonstrated moderate aortic insufficiency with a continuous-wave Doppler pressure half-time of 216 msec, an elevated left ventricular outflow tract velocity-time integral of 33.1 cm, and peak velocities of approximately 3.8 m/sec.
Subsequent TEE revealed an aortocavitary fistula with continuous color Doppler flow from the aorta to the right atrium, which had been obscured on TTE by turbulent Doppler signals from aortic stenosis, aortic regurgitation, and tricuspid regurgitation.
The identification of the acute left-to-right shunt and preserved right ventricular size prompted emergent surgical intervention, leading to full clinical recovery.

Study Design

Type

Case Report (n=1)

Multicenter

No

PICO

P

Population

1 female patient (age 70) with a bicuspid aortic valve and Streptococcus mitis/oralis infective endocarditis complicated by an aortocavitary fistula, treated with surgical repair and 6 weeks of intravenous ceftriaxone.

I

Intervention / Comparator

Transesophageal echocardiography-guided surgical aortic root replacement, right atrial debridement, pericardial patch fistula repair, and intravenous ceftriaxone vs Transthoracic echocardiography (for diagnostic comparison)

O

Primary Outcome

Diagnosis and surgical resolution of occult aortocavitary fistula

Limitations

Single-patient case report design limits generalizability.
Transthoracic echocardiography failed to visualize the continuous left-to-right fistula flow due to turbulent Doppler signals from concomitant valvular stenosis and regurgitation.
Acute aortic insufficiency severity was likely underestimated on initial imaging due to elevated left ventricular end-diastolic pressures.

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Implication

TEE may detect occult aortocavitary fistulas missed by TTE in endocarditis; leaves open whether routine TEE improves outcomes.

Abstract

•Aortocavitary fistula is a rare but potentially lethal complication of IE.•A bicuspid AV may confer higher risk for periannular complications due to IE.•TEE is superior to TTE for diagnosis of IE and related complications.

Discussion

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Cite This Study

Nguyen et al. (2018) conducted a case report in Infective endocarditis complicated by an occult aortocavitary fistula (n=1). Transesophageal echocardiography-guided surgical aortic root replacement, right atrial debridement, pericardial patch fistula repair, and intravenous ceftriaxone vs. Transthoracic echocardiography (for diagnostic comparison) was evaluated on Diagnosis and surgical resolution of occult aortocavitary fistula.

synapsesocial.com/papers/6adf4322061266ab9fc14ca5 https://doi.org/10.1016/j.case.2018.09.003

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An Occult Aortocavitary Fistula Presenting as Apparent Tricuspid Valve and Aortic Valve Endocarditis

Key Points

Study Design

PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

An Occult Aortocavitary Fistula Presenting as Apparent Tricuspid Valve and Aortic Valve Endocarditis

Key Points

Study Design

PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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