Author + information
- Received August 31, 2017
- Revision received September 14, 2017
- Accepted September 19, 2017
- Published online April 2, 2018.
- Soumya Patra, MD, DMa,∗ (, )
- Sumanto Mukhopadhyay, MD, DMa,
- Arindam Pande, MD, DMa,
- Rabin Chakraborty, MD, DMa,
- Nandita Chakrabarti, MDb and
- Kunal Sarkar, MBBSc
- aDepartment of Interventional Cardiology, Medica Superspecialty Hospital, Kolkata, India
- bDepartment of Non-Invasive Cardiology, Medica Superspecialty Hospital, Kolkata, India
- cDepartment of Cardiothoracic Surgery, Medica Superspecialty Hospital, Kolkata, India
- ↵∗Address for correspondence:
Dr. Soumya Patra, Department of Interventional Cardiology, Medica Superspecialty Hospital, 127, Mukundapur, EM Bypass, Kolkata, West Bengal, India.
A 22-year-old woman presented with new-onset palpitation and dyspnea. Cardiovascular examination revealed continuous murmur at the left upper parasternal area. Echocardiographic evaluation revealed a connection from the aorta, tunneling up to the intra-atrial septum, which made a giant aneurysmal chamber and which then emptied into the right atrium (RA), behaving like a cor triatriatum dextrum (Figures 1A, 1B, and 2). Our heart team decided to close this aorto-atrial fistula percutaneously. Cardiac catheterization confirmed the presence of a left-to-right shunt with a pulmonary-to-systemic blood flow ratio of 1.9:1. Angiography revealed a largely dilated channel originating from the right coronary sinus separately from the right coronary artery, connecting to the RA after making a giant aneurysmal sac (Figure 3, Online Video 1). This tunnel was entered from the aortic end by using a 6-F Judkins right guide catheter over a 0.014-inch coronary and 0.035-inch Terumo wire (Terumo, Tokyo, Japan). An arteriovenous loop was formed by snaring the Terumo wire from the pulmonary artery. This tunnel had a widest diameter of 9.5 mm and narrowest diameter of 6.6 mm. A 7-F delivery sheath was then taken and placed into the aneurysmal cavity through which a 14-mm Amplatzer Vascular Plug II (St. Jude Medical, St. Paul, Minnesota) was deployed antegradely (Figure 4, Online Video 2). After releasing the device, the selective and aortic root angiograms showed complete closure of the tunnel. There was normal flow in the right coronary artery and absence of any aortic regurgitation (Figure 5, Online Video 3). The patient was completely asymptomatic at 1-month follow-up, and echocardiography revealed no flow across the tunnel, with a collapsed aneurysmal sac (Figure 6).
The aorto-atrial fistula is a rare variant of congenital aorto-cameral fistula, most frequently originating from the left coronary sinus (1). The present report emphasizes the role of percutaneous closure of this congenital cardiac anomaly (2). To the best of our knowledge, it is the first case of aorto-RA fistula in which the Amplatzer vascular plug was used. Large available sizes and easy antegrade deliverability made this device appropriate in this large fistula.
The authors sincerely acknowledge the role of Dr. Anil Singhi, pediatric cardiologist, in performing the transesophageal echocardiography, and Dr. Somnath Dey, cardiac anesthesiologist, for assisting in this case. The authors also thank Arnab De and his catheterization laboratory team for technical support.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received August 31, 2017.
- Revision received September 14, 2017.
- Accepted September 19, 2017.
- 2018 American College of Cardiology Foundation
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