Aorta-right ventricular fistulisation following staphylococcal aureus endocarditis of prosthetic aortic valve in a Tetralogy of Fallot patient
2011 (English)In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 151, no 2, e42Article in journal (Refereed) Published
Perivalvular extension of infection in Prosthetic Valve Endocarditis (PVE) is frequent and associated with high rates of heart failure and death. Patients with PVE due to staphylococcal aureus are particularly prone to increased mortality and complications. Aorto-cavitary fistulisation, however, is a rare complication, the most common involve the right coronary sinus to right ventricle, the non-coronary sinus to right ventricle and the left coronary sinus to the left atrium. A 44-year-old woman with Tetralogy of Fallot repair and prosthetic aortic valve replacement for endocarditis presented with fever, chest pain and dyspnoea, and was commenced on intravenous antibiotics. A transesophageal echocardiography (TOE) showed no vegetations or stigmata of residual Tetralogy of Fallot apart from some degree of right ventricular outflow tract (RVOT) narrowing. Marked aortic dilatation (4.8 cm in diameter) was noted. A wide complex ventricular tachycardia (VT) with left bundle branch block (LBBB) was also documented, for which further electrophysiological studies were planned. Four weeks after the first presentation the patient returned with worsening dyspnoea. A chest X-ray showed right middle lobe infiltrate with an enlarged heart. A transthoracic echocardiogram showed significant left ventricular dysfunction (Ejection fraction 35%). The patient arrested, was resuscitated and was transferred to intensive care with multi-organ failure, requiring intubation and intra-aortic balloon pump insertion. A TOE demonstrated continuous flow from the aorta to the anterior wall of the RVOT. No vegetations or abscess formation were seen. Surgery for fistula repair and prosthetic valve re-do was planned for the next day but unfortunately, the patient became progressively shocked and died. The association of Tetralogy of Fallot and infective endocarditis and the risk of prosthetic valve related complications are well documented but fistula formation between the aorta and right ventricle is very rare. Such a fistula on a background of Tetralogy of Fallot is undocumented. The presence of the fistula suggests that the abscess may have tracked across the ventricular septal defect repair patch, and hence the possibility of heart block, even in the absence of obvious echocardiographic evidence for infection. In this case the serious complication however, was the VT with LBBB. VT is seen in some Tetralogy of Fallot patients, but the strange presentation coupled with the rarity of the anatomical complication made management very challenging. The destructive power of Staphylococcus aureus Endocarditis is known, particularly in repaired Tetralogy of Fallot. However, the addition of serious arrhythmia to the clinical presentation should always be recognized as a potential threatening complication.
Place, publisher, year, edition, pages
Amsterdam: Elsevier, 2011. Vol. 151, no 2, e42
Cardiac and Cardiovascular Systems
IdentifiersURN: urn:nbn:se:umu:diva-34736DOI: 10.1016/j.ijcard.2009.11.026ISI: 000294476300003PubMedID: 20172614OAI: oai:DiVA.org:umu-34736DiVA: diva2:324405