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A previously well patient aged 20-plus years, underwent laparotomy following abdominal stab injuries. Bowel lacerations were identified and closed. Through a diaphragmatic defect, a small right atrial puncture was noted which was closed with cardiothoracic surgical assistance. No further injuries were identified. The patient was intubated and ventilated and on inotropic support with a blood pressure of 140/40 mm Hg. The patient's blood pressure later dropped to 100/30 mm Hg and plans were made for further abdominal imaging and re-laparatomy. In the meantime, transthoracic echocardiography (TTE) showed good left and right ventricular function and there was no pericardial effusion. However, the echocardiogram suggested severe aortic regurgitation (figure 1A), and there was a suspicious colour Doppler flow signal noted (figure 1B) through which continuous-wave Doppler velocities were recorded (figure 1C).
What does the imaging show?
Aortic regurgitation due to bicuspid aortic valve.
Aortic regurgitation with fistula between non-coronary cusp and right atrium.
Aortic regurgitation with fistula between right coronary cusp and right atrium.
Aortic regurgitation with fistula between left coronary cusp and left atrium.
Aortic regurgitation through congenital aorto-right atrial tunnel.
Aortic regurgitation due to ruptured sinus of Valsalva aneursym.
For the answer see page 1062
From the question on page 1050
The correct answer is option 2. The transthoracic colour Doppler imaging shows turbulent colour flow suggestive of aortic regurgitation and further flow between the non-coronary cusp and the right atrium. The continuous-wave Doppler through the turbulent flow shows a high-velocity continuous flow signal throughout the cardiac cycle suggesting aorto-right atrial fistula. Option 1 is incorrect, as a trileaflet aortic valve is clearly seen. In the TTE short-axis view of the aortic valve, the right coronary cusp lies anteriorly, and the left coronary cusp lies to the right of the images, so options 3 and 4 are incorrect. Option 5 is incorrect as congenital aorto-right atrial tunnels do not tend to involve the aortic valve cusps, and option 6 is incorrect as there is no evidence of a sinus of Valsalva aneurysm on the images.
The patient underwent transoesophageal echocardiography (figure 2 and see online supplementary videos 1 and 2) which confirmed an aorto-right atrial fistula and a prolapsing non-coronary cusp through which most of the aortic regurgitation was occurring. As a result of these images, the patient was transferred to a cardiothoracic surgical centre. At the time of operation, a 1 cm perforation in the aortic non-coronary sinus communicating with a defect in the superior medial wall of the right atrium was found. Additionally a perforation in the aortic non-coronary cusp was noted. These were both from the tip of the knife. The patient successfully underwent a root-sparing closure of the fistula and had a mechanical aortic valve replacement.
Aorto-right atrial communications can be congenital, or acquired following rupture of a sinus of Valsalva aneurysm, due to aortic dissection, as a rare complication following endocarditis, or through traumatic injury. This case highlights the sensitivity of echocardiography to guide surgical intervention despite previous surgical exploration of the area.
Contributors ASML, PRG and CAM wrote the manuscript, with RA, AMB and ICC editing it subsequently. RA and AMB obtained the echocardiographic pictures and videos, and the patient was under the care of ICC. ASML takes responsibility for the overall content as guarantor.
Competing interests None.
Provenance and peer review Not commissioned; internally peer reviewed.