Case Report Published on December 30, 2023

 

Aortocavitary Fistula to Right Ventricle: A Rare Complication of Infective Endocarditis 

Arun Kunjappan Philip^a, Vinu C V^a, Niwin George^a, Kishore Lal^a, Akhil Sreedharan  Nair^a, Parvathy Priya Yoganadhan^a

a. Department of Cardiovascular and Thoracic Surgery, Governement Medical College, Thiruvanathapuram *

abstract

Aortocavitary fistulas are one of the rare complications of infective endocarditis. These fistulas can even cause cardiac failures which mandate a surgical correction. This is a case report of a 38-year-old male who is a known case of rheumatic valvular heart disease, developed aortocavitary fistula following an attack of infective endocarditis.

Keywords: Infective Endocarditis, Aortocavitary fistula

 

Introduction

Infective endocarditis (IE) predominantly occurs in valves with preexisting pathology.IE is a disease with relatively high morbidity and mortality with an annual incidence of13.8 cases per 100000 subjects.¹ Patients with rheumatic heart disease have an intermediate risk of IE^[1].IE can present in various forms depending upon the degree of involvement of valve leaflets and sub valvular apparatus. Abscess formation and development of pseudoaneurysm can lead to abnormal communication between the aortic root and various cardiac chambers called Aortocavitary fistula (ACF).²

CASE REPORT

A 38-year-old male k/c/o  rheumatic heart disease presented to the outpatient  department (OPD) with fever and breathlessness. He was diagnosed to have rheumatic fever with valvular involvement in 2006 and was on irregular follow up. Patient is a smoker. No surgical intervention in past.

Patient had on and off fever for past 2 weeks. one or two fever episode per day. Fever was associated with chills and rigor. Breathlessness started one week after fever. Occurred during exertion and no history of orthopnoea.

Examination of the patient showed a radial pulse of high volume and collapsing  nature with a rate of 85 beats/min blood pressure 100/40 mm of Mercury, oxygen saturation (SPo2)  96% in  room air. Examination of cardiovascular system  showed an apex beat at left  6^th intercostal space 2cm lateral to midclavicular line which was diffuse and forceful in character. 2/4 long end diastolic murmur in aortic area and 3/6 pan systolic murmur at the apex. Traube sign and Durozeiz sign and Quincke sign were present. On examination  abdomen, no visible or palpable pulsation were present. Skin did not show any focus of infection but multiple infected teeth were present.

Figure 1. Echo showing aortic vegetation and thickened aortic valve

Laboratory showed haemoglobin of 8.8g/dl, Total WBC count 14000 with differential count of N85,L15,ESR 50mm/hr, renal function test and liver function tests parameters were in normal range. Trans thoracic echocardiogram (TTE) showed a thickened aortic valve with vegetation, severe aortic insufficiency and mild mitral regurgitation (Figure1). Blood culture showed growth of Staphylococcus aureus  sensitive to vancomycin and ceftriaxone. Patient was on antibiotics for 21 days. Repeated blood cultures were negative for bacterial and fungal growth. During the course of hospital stay infected teeth were extracted and patient developed features of cardiac failure. Repeat TTE and TEE showed and vegetation in aortic valve (1.5cm x 1cm) with severe aortic insufficiency and fistulous tract between right coronary sinus and right ventricle (Figure 2).

Figure 2. Showing fistulous tract between aorta and right ventricle

Surgical correction of severe aortic insufficiency(Aortic valve replacement using 23mm TTk Chitra mechanical tilting disc valve) and primary closure aortic end of fistulous tract using pledgeted sutures along with debridement of all infected tissue (Figure 3). Post-operative period was uneventful. Echo done on post-operative day 5 showed normal functioning prosthetic valve with preserved ventricular function and no residual shunt.

Figure 3. Intraoperative picture showing opening of aortocavitary fistula in the right coronary sinus

Discussion

Formation of periannular abscesses are known complication of IE.^[3] However, progression of periannular abscess into ACF is about 2.2% in native valve endocarditis and is about 5.8% individuals with prosthetic valve endocarditis.^3,4 Destruction of valvular and perivalvular tissue by infectious organism cause formation of ACF. This abnormal pathways can cause flow dynamic similar to other valvular pathologies. ACF causing left to right shunt can cause significant hemodynamic instability.^4,6

Prevalent organism causing IE are Staphylococcus aureus, Streptococcus spp, Enterococcus spp.⁴ Infections of the skin, genitourinary tract, oral cavity, direct inoculation are the  common entry points of organism to blood. Patient with rheumatic heart disease have an intermediate risk of developing IE.¹ Clinical presentation of ACF can vary from an insignificant murmur to overt cardiac failure. Size of the shunt is an important parameter in determining the severity of disease and clinical course. Common type of ACF are aorto-right atrial type or aorto-pulmonary type. Aorto-right ventricular fistulas are far more less common.⁵

 ACF predominantly occur as result of infection of  prosthetic valve in aortic position followed by infection native aortic valve and rarely in right sided valve infection. Echocardiography is the initial investigation in evaluating IE. Even though TTE is easy to perform and less invasive, TEE provide  more information regarding anatomy of valves and its function.⁶

Cardiac CT is an excellent complimentary investigation especially when echocardiography is inconclusive. Cardiac CT provide information regarding coronary anatomy which precludes invasive coronary angiography.⁶

Surgical correction is considered to be the preferred treatment of ACF. It mainly includes removal of all necrotic valvular and perivalvular tissue, exclusion of fistulous tract and if necessary valve replacement. Valve replacement can be performed using mechanical or bioprosthetic valve, pulmonary autograft or homograft. Surgical management is associated with a 92% freedom from recurrent infection. About 75% cases were free of reoperation for a time span of 17 years.⁷ Mortality associated with surgical management ranges from 13%-26%.⁸ Transcatheter closure of ACF has also been met with variable success.⁷

Conclusion

Fever in patients with known valvular heart disease and new cardiac murmurs should be promptly evaluated. Destruction of valvular and paravalvular tissue can lead to rare complications. Surgical corrections plays an important role management of many of the complications of IE.³

Conflict of interest and funding: The authors have not received any funding or benefits from industry or elsewhere to conduct this study.

Ethics approval: This case report does not require ethical approval. Consent was taken from patient for publishing data.

Data availability: Data regarding study is available with corresponding author. Data will be provided at request.

End Note

Author Information

1. Arun Kunjappan Philip, Department of Cardiovascular and Thoracic Surgery, Governement Medical College, Thiruvanathapuram.
2. Vinu C V, Department of Cardiovascular and Thoracic Surgery,  Governement Medical College, Thiruvanathapuram.
3. Niwin George, Department of Cardiovascular and Thoracic Surgery, Governement Medical College, Thiruvanathapuram.
4. Kishore Lal, Department of Cardiovascular and Thoracic Surgery, Governement Medical College, Thiruvanathapuram.
5. Akhil Sreedharan  Nair, Department of Cardiovascular and Thoracic Surgery, Governement Medical College, Thiruvanathapuram.
6. Parvathy Priya Yoganadhan, Department of Cardiovascular and Thoracic Surgery, Governement Medical College, Thiruvanathapuram.    

Conflict of Interest: None declared

REFERENCES

1. Delgado, Victoria, Nina Ajmone Marsan, Suzanne de Waha, Nikolaos Bonaros, Margarita Brida, Haran Burri, Stefano Caselli, et al. “2023 ESC Guidelines for the Management of Endocarditis.” European Heart Journal 44, no. 39 (October 14, 2023): 3948–4042.
   [Pubmed] | [Crossref]
2. Galeas JN, Perez IE, Villablanca PA, Chahal H, Jackson R, Taub CC. Aortocavitary fistula as a complication of infective endocarditis and subsequent complete heart block in a patient with severe anemia. Journal of Community Hospital Internal Medicine Perspectives. 2015 Jan 1;5(6):29446.
   [Pubmed] | [Crossref]
3. Sanchez-Nadales, Alejandro, Valentina Celis-Barreto, Amir Khan, Andrea Anampa-Guzman, and Olalekan Olanipekun. “Aorto-Cavitary Fistula to the Left Ventricle with Severe Aortic Regurgitation as a Complication of Prosthetic Valve Infective Endocarditis: A Novel Report.” Oxford Medical Case Reports 2020, no. 12 (December 2020): omaa109.
   [Pubmed] | [Crossref]
4. Anguera I, Miro JM, Evangelista A, Cabell CH, San Roman JA, Vilacosta I, Almirante B, Ripoll T, Fariñas MC, Anguita M, Navas E. Periannular complications in infective endocarditis involving native aortic valves. The American journal of cardiology. 2006 Nov 1;98(9):1254-60.
   [Pubmed] | [Crossref] 
5. Inanc IH. Does intervention always essential for aorto-right ventricular outflow tract fistula after surgical aortic valve replacement?: A case report. Journal of Clinical Medicine of Kazakhstan. 2020 Oct 25;5(59):54-6.
   [Pubmed]
6. Anguera, Ignasi, Jose M. Miro, Isidre Vilacosta, Benito Almirante, Manuel Anguita, Patricia Muñoz, Jose Alberto San Roman, et al. “Aorto-Cavitary Fistulous Tract Formation in Infective Endocarditis: Clinical and Echocardiographic Features of 76 Cases and Risk Factors for Mortality.” European Heart Journal 26, no. 3 (February 2005): 288–97.
   [Pubmed] | [Crossref]
7. Sadic E, Esmail K, Percy R, Missov E, Sattiraju S. A Shortcut to Death: Aorto–Left Atrial Fistula in the Setting of MRSA Infective Endocarditis. CASE: Cardiovascular Imaging Case Reports. 2020 Jun;4(3):195.
   [Pubmed] | [Crossref]
8. Kirali K, Omeroglu SN, Mansuroglu D, Ipek G, Yakut C. Aortic root abscess with fistula formation into right ventricular myocardium. Türk Kardiyol Dern Arş. 2000 Oct 1;28:647-9.
   [Source]