A postoperative left ventricular-right atrial shunt due to infectious endocarditis after aortic repair with aortic valve replacement detected by transesophageal echocardiography
© The Author(s) 2016
Received: 9 June 2016
Accepted: 23 September 2016
Published: 29 September 2016
Infectious endocarditis (IE) with acute heart failure is a medical emergency. In particular, postoperative IE after aortic repair with an artificial vascular graft is a life-threatening matter. We present a case in which a mobile abscess appeared on the aortic valve annulus with an intra-cardiac shunt in the left ventricle (LV) to the right atrium (RA) after ascending aortic repair with aortic valve replacement (AVR) for acute type A aortic dissection. It was diagnosed with transesophageal echocardiography (TEE), which prompted further exploration.
Intra-cardiac shunts in the left ventricle (LV) to the right atrium (RA) are mostly congenital . Similar acquired shunts are reported as follows: chest trauma, mitral and aortic valve replacement, or infectious endocarditis (IE) [2, 3]. In particular, intra-cardiac shunts with periannular abscesses related to IE have been reported in 14 % of patients after prosthetic valve replacement . We present a case in which a mobile abscess appeared on the aortic valve annulus with an intra-cardiac shunt in the LV to the RA after ascending aortic repair with aortic valve replacement (AVR) for acute type A aortic dissection. It was diagnosed with transesophageal echocardiography (TEE), which prompted further exploration.
After the patient complained of the abnormality, the authors firstly inserted the PAC to evaluate the cardiac function. This revealed abnormal increased mixed venous blood oxygen saturation. Among many causes of increased mixed venous blood oxygen saturation, an intra-cardiac left to right shunt is one of the possible causes because of acute appearance of dyspnea. Although the patient unfortunately died of acute heart failure due to IE, decisive diagnosis without delay was required for performing adequate treatment. Although TTE revealed both the vegetation on the peri-aortic root and abnormal flow in the RA, the detailed site of the intra-cardiac shunt was difficult to detect. Because TEE depicts the subaortic structures clearly using an acoustic window from both of the LA and the RA, TEE depicts the structures better than TTE . One of the tips for clearly depicting the detailed site of the LV-RA shunt is to adjust the aliasing velocity appropriately . The authors adjusted the aliasing velocity at 30.8 cm/ms. Because pressure gradient between the LV and the RA decreases due to pressure overload at the RA, a relative slow velocity of shunt flow was predicted. Furthermore, three-dimensional TEE revealed the exact location of the vegetation attached to the aortic root structures. In this aspect, TEE examination in the ICU was a crucial diagnostic method to decide emergent surgical revision.
Although the patient died of acute heart failure due to infectious endocarditis, TEE information could be helpful for depicting the exact location of the fistula and for guiding the surgical procedure.
Left coronary cusp of the aortic valve
Noncoronary cusp of the aortic valve
Right coronary cusp of the aortic valve
TS was involved in patient care during the operation and prepared the manuscript. JN carried out the TEE study and substantially contributed to drafting the manuscript. MK drew the schema of the venous malformation. TM helped draft the manuscript. All authors read and approved the manuscript.
TS is an Associate Professor at the Department of Anesthesiology, Osaka Medical College. JN is an Assistant Professor at the Department of Anesthesiology, Osaka Medical College. MK is an Assistant Professor at the Department of Anesthesiology, Osaka Medical College. TM is a Professor at the Department of Anesthesiology, Osaka Medical College.
The authors declare that they have no competing interests.
Consent for publication
Written informed consent for publication was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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- Gerbode F, Hultgren H, Obsborn J. Syndrome of left ventricular-right atrial shunt: successful surgical repair of defect in five cases, with observation of bradycardia on closure. Ann Surg. 1958;148:433–46.View ArticlePubMedPubMed CentralGoogle Scholar
- Sabik JF, Lytle BW, Bkackstone EH, Marullo AG, Pettersson GB, Cosgrove DM. Aortic root replacement with cryopreserved allograft for prosthetic valve endocarditis. Ann Thorac Surg. 2002;74:650–9.View ArticlePubMedGoogle Scholar
- Stechert MM, London MJ. Native aortic root endocarditis with invasion of the right outflow tract. Anesth Analg. 2010;110:36–8.View ArticlePubMedGoogle Scholar
- Silverman NA, Sethi GK, Scott SM. Acquired left ventricular-right atrial fistula following aortic valve replacement. Ann Thorac Surg. 1980;30:482–6.View ArticlePubMedGoogle Scholar
- Walmsley R, Watson H. The medial wall of the right atrium. Circulation. 1966;3:400–11.View ArticleGoogle Scholar
- Karalis DG, Bansal RC, Hauck AJ, Ross Jr JJ, Applegate PM, Jutzy KR, Mintz GS, Chandrasekaran K. Transesophageal echocardiographic recognition of subaortic complications in aortic valve endocarditis. Clinical and surgical implications. Circulation. 1992;86:353–62.View ArticlePubMedGoogle Scholar
- Stechert MM, Kellermeier JP. Aorto-atrial fistula: an important complication of aortic prosthetic valve endocarditis. Anesth Analg. 2007;105:332–3.View ArticlePubMedGoogle Scholar