5. Kawasuji M, Sakakibara N, Matsumoto Y, Watanabe Y,Shimizu K. Occlusion of the left coronary ostium due tofusion of the aortic cusp to the wall. Ann Thorac Surg 1995;59:233–4.

6. Kalimi R, Palazzo RS, Graver LM. Occlusion of LCA ostiumby an aortic valve cusp. Ann Thorac Surg 2000;69:637–9.

7. Edwards JE. Pathology of left ventricular outflow tract ob-struction. Circulation 1965;31:586–99.

8. Ergin MA, Spielvogel D, Apaydin A, et al. Surgical treatmentof the dilated ascending aorta: when and how? Ann ThoracSurg 1999;67:1834–9.

Aorto-Atrial Fistula Through theSeptum in Recurrent AorticDissectionClaudio Russo, MD, Francesca De Chiara, MD,Giuseppe Bruschi, MD, Guglielma Rita Ciliberto, MD,and Ettore Vitali, MD

Departments of Cardiac Surgery and Cardiology, OspedaleNiguarda Ca’ Granda, Milan, Italy

A case of aortic dissection (De Bakey type I) with a fistulato the right atrium through the interatrial septum, diag-nosed by transthoracic and transesophageal echocardiog-raphy is reported. The patient presented with cardiacfailure and a continuous murmur in the right second andthird intercostal spaces. The patient underwent success-ful operative repair.

(Ann Thorac Surg 2001;72:921–2)© 2001 by The Society of Thoracic Surgeons

Aortic dissection with rupture into the right atrium isa rare complication and fatal if untreated [1]. Trans-

thoracic echocardiography and the improved imagequality of transesophageal echocardiography provide thecapability of early diagnosis for an emergency operation.

The patient, a 70-year-old woman, obese, with insulin-dependent diabetes, was admitted into our hospital be-cause of chest pain and dyspnea. At the same institution6 years earlier she underwent emergency ascendingaorta replacement with a 30 mm polyester vascular graft,Albograft (Sorin Biomedica Cardio S.p.A., Saluggia, Italy)for acute De Bakey type I aortic dissection. She was welluntil 4 days before the admission, when she experiencedacute, severe precordial pain and dyspnea. She subse-quently experienced orthopnea and pulmonary edema.

Physical examination revealed a blood pressure of150/70 mm Hg, a heart rate of 100 beats/min, signs ofcongestive heart failure with pulmonary rales, and ele-vated jugular venous pressure. She had a grade 3/6

continuous systolic and diastolic murmur at the fourthintercostal space.

The electrocardiogram showed sinus tachycardia withan incomplete right bundle branch block pattern. Radi-ography of the chest showed pulmonary edema.

Despite intensive medical treatment, she had refrac-tory and progressive heart failure. Transthoracic echocar-diography showed a normal-sized left ventricle withhyperdynamic function. Right atrium and ventricle wereboth moderately dilated. The ascending aorta was abnor-mal with an adjacent echo-free space 2 cm distal to theaortic valve, representing the false lumen of an aorticdissection (Fig 1A). Color flow Doppler study in theapical four chamber view revealed a rent between theaorta and the right atrium with continuous flow (Fig 1B).Multiplane transesophageal echocardiography (per-formed with an Acuson Sequoia C 256, Acuson Corpora-tion, Mountain View, CA) confirmed the diagnosis ofremaining aortic root dissection and a communicationbetween the noncoronary aortic sinus and right atrium;these findings looked consistent with a fistula to the rightatrium from the dissected aorta through the interatrialseptum. It was not possible to perform a coronary an-giography because of aortic root severe deformation.

The patient underwent an emergency operation. Thechest was reopened through a middle resternotomy.Dense adhesions were present between the aortic pros-thesis, the sternum, the superior vena cava, and the rightatrium. Cardiopulmonary bypass was established andascending aorta was cross-clamped in the upper part,beyond the distal anastomosis of the tubular prosthesis.Anterograde/retrograde blood cardioplegia was deliv-ered continuously. The right atrium was opened. Theaorta was entered at the level of proximal anastomosis,beyond the sinotubular junction.

The new dissection originated from the previous prox-imal anastomosis and was limited to the noncoronarysinus of Valsalva. Both the right and left coronary sinusdid not show dissection. The aortic valve leaflets weremorphologically normal, but the noncoronary cusp wasprolapsing secondary to the dissection of the correspond-ing sinus. The intramedial dissection channel, gettingthrough the aortic annulus corresponding to the sameaortic sinus and the underlying interatrial septum,formed a fistula (3 3 1.5 cm) that perforated the rightatrium wall; the outlet rupture was just 1.5 cm away fromthe coronary sinus ostium. The former vascular prosthe-sis was removed and a new one was implanted withreconstruction of the sinotubular junction at the level ofthe right and left coronary sinus. At the proximal end, theprosthesis was scalloped in order to reconstruct thedissected noncoronary sinus. The aortic annulus wasreinforced with a felt strip. With this reconstruction, thecranial portion of fistula corresponding to sinus of Val-salva was eliminated. The lower part of the fistula, layingin the interatrial septum was obliterated with biologicalglue and the outlet rupture in the right atrium wassutured with pledget-reinforced sutures.

The distal end of the prosthesis was anastomosed to

Accepted for publication Sept 22, 2000.

Address reprint requests to Dr Russo, Department of Cardiac Surgery “A.De Gasperis,” Ospedale Niguarda Ca’ Granda, Piazza Ospedale Mag-giore, 3 20162 Milan, Italy; e-mail: cf.russo@tiscalinet.it.

921Ann Thorac Surg CASE REPORT RUSSO ET AL2001;72:921–2 AORTO-ATRIAL FISTULA THROUGH THE SEPTUM

© 2001 by The Society of Thoracic Surgeons 0003-4975/01/$20.00Published by Elsevier Science Inc PII S0003-4975(00)02478-4

the distal ascending aorta. The right atriotomy wassutured.

Postoperative transesophageal echocardiography didnot show any residual communication between the aortaand right atrium. The aortic valve appeared normal infunction without insufficiency. The patient was extubatedthe day after the operation and discharged on postoper-ative day 10. At 3 months follow-up, she is alive, andfunctional in New York Heart Association’s class I.

Comment

This case describes an unusual complication of a previ-ous operation of an aortic acute dissection. The frequencyof aortocamera fistula in patients with previous opera-tions suggests postoperative adhesions as pathogeneticmechanism [2]. This condition should be suspected in

these kinds of patients, showing chest pain and cardiacfailure, continuous murmur, and evidence of right ven-tricle volume overload. Transthoracic echocardiographyand transesophageal echocardiography are the tech-niques of choice for diagnosis and allow for a promptsurgical repair [3].

In this case, the aortic valve sparing procedure allowedrepair of the aorto-atrial fistula and avoided valve re-placement with a prosthesis.

References

1. Page AJF, Yacoub MH, Sutton GC. Aorto-right atrial fistula: arare complication of aortic dissection. Br Heart J 1973;35:1338–40.

2. Fujii H, Oka T, Kawaguchi H, et al. Aorto-atrial fistulaassociated with recurrent aortic dissection after ascendingaorta replacement. J Cardiovasc Surg 1998;39:817–9.

3. Caruso A, Iarussi D, Materazzi C, Dialetto G, Covino F,Bossone E. Aortic dissection with fistula to left atrium: diag-nosis by transesophageal echocaardiography with successfulrepair. J Am Soc Echocardiogr 2000;13:69–72.

Glue Aortoplasty Repair of AorticDissection After CoronaryAngioplastyAlsir A. M. Ahmed, FRCS, Vaikom S. Mahadevan,MRCP, Samuel W. Webb, FRCP, and Simon W.MacGowan, FRCSI (CTh)

Cardiac Surgical Unit and Regional Medical CardiologyCentre, Royal Victoria Hospital, Belfast, Northern Ireland

Aortic dissection complicating percutaneous translumi-nal coronary angioplasty is rare. We report the case of a45-year-old man who after right coronary artery angio-plasty with stenting, dissected that vessel to involve theaorta to the bifurcation. Surgical repair with Gelatin-Resorcinol-Formaldehyde (GRF) glue as opposed to pros-thetic graft replacement of the ascending aorta was suc-cessful. The use of GRF glue is effective in the surgicaltreatment of aortic dissection after coronary angioplasty.

(Ann Thorac Surg 2001;72:922–4)© 2001 by The Society of Thoracic Surgeons

Aortic dissection complicating percutaneous translu-minal coronary angioplasty is rare. Surgical repair

with Gelatin-Resorcinol-Formaldehyde (GRF) glue is analternative to prosthetic graft replacement of the ascend-ing aorta can be successful and is effective in the surgicaltreatment of aortic dissection after coronary angioplasty.

Accepted for publication Sept 22, 2000.

Address reprint request to Mr MacGowan, Cardiac Surgical Unit, TheRoyal Victoria Hospital, Grosvenor Rd, Belfast BT12 6BA, NorthernIreland; e-mail: simon.macgowan@royalhospitals.n-i.nhs.uk.

Fig 1. (A) Transesophageal echocardiogram demonstrating the falselumen of the aortic dissection along the ascending aorta. (AO 5ascending aorta; LA 5 left atrium; LV 5 left ventricle; RV 5 rightventricle.) (B) Transesophageal echocardiogram with color flowDoppler reveals bright mosaic color jet of high velocity originatingwithin the aorta and entering the right atrium. (AO 5 ascendingaorta; LA 5 left atrium; RA 5 right atrium.)

922 CASE REPORT AHMED ET AL Ann Thorac SurgGLUE AORTOPLASTY 2001;72:922–4

© 2001 by The Society of Thoracic Surgeons 0003-4975/01/$20.00Published by Elsevier Science Inc PII S0003-4975(01)02472-3