Ascites After Rupture of Dissecting Aortic Aneurysm Into the Right Atrium Axel Ch. Henze, MD, Jan B. Thorelius, MD, Jan W. Borowiec, MD, Ebba H. Enghoff, MD, and Johan B. Thurkn, MD Departments of Thoracic and Cardiovascular Surgery, Cardiology, and Diagnostic Radiology, University Hospital, Uppsala, Sweden

ormation of an aorta-right atrial fistula is a rare com- F plication of aortic dissection [l]. Rupture into the right heart is often fatal [2,3], but a few cases of successful surgical repair have been reported [l, 2, 41. The clinical findings in these patients were relatively uniform, com- prising dissection and right ventricular overload. We describe a case in which intractable ascites developed.

We report successful repair of an aneurysmal aorta-right atrial fistula causing intractable ascites. The clamped ”ascending aorta” was drained for mixed return after perfusion through the femoral vessels and opened dur- ing hypothermic arrest. Return cannulation through the fistula permitted definitive repair.

(Ann Thorac Surg 1991;51:125-7)

A C

B D Fig 1 . Magnetic resonance irn[i~irig hefore operation (A, B) and at 1-year follo7cwp (C, D). Arrows indicate dissection near the aortic annulus, extending into the descendiq aorta, ie, de Bake?/ type I .

Accepted for publication June 28, 1990

Address reprint requests to Dr Thorelius, Department of Thoracic and Cardiovascular Surgery, University Hospital, 5-751 85 Uppsala, Sweden.

0 1991 by The Society of Thoracic Surgeons 0003-4975/91/$3.50

126 CASE REPORT HENZE ET AL ASCITES AFTER ANEURYSMAL RUPTURE

Ann Thorac Surg 1991 :51: 125-7

Fig 2. Steps of the repair. (DA = descending coro- n a y artery; IVC = inferior vena cava; PA = pulmo- n a y artery; SVC = superior vena cava.)

The patient underwent an uncomplicated aortic valve replacement at age 45 years owing to severe aortic insuffi- ciency. The ascending aorta, however, was found to be dilated, with thinning of its wall. Three months later he suffered a de Bakey type I aortic dissection (Fig 1). Operation was not considered at that stage because the aortic pros- thetic valve was competent, an unwise decision as after 3 years the patient had intractable ascites. A prominent sys- todiastolic cardiac murmur, magnetic resonance imaging, angiography, and cardiac catheterization confirmed the presence of an aorta-right atrial fistula with 75% shunt.

Repair was begun with perfusion through the femoral artery and vein. At sternotomy the right atrium was beyond reach and therefore the aorta was clamped prox- imal to the truncus, after which the aneurysm was can- nulated for return and mixed right to left bypass to full flow. At 20°C central temperature the aneurysm was opened during circulatory arrest, the return cannula was guided through the fistula to the right atrium, and full

flow was reestablished. Despite gross pathology of the ascending aorta, the prosthetic valve site and coronary orifices were without major disease and an intimal rup- ture at the aortotomy suture line was the probable source of the dissection and fistulation. The aneurysm was replaced with a tubular graft and the fistula was closed at decannulation (Fig 2). Weaning from cardiopulmonary bypass was uneventful with normalized pulmonary artery pressure, from 70 mm Hg systolic.

The postoperative course was benign without recur- rence of ascites and the anatomical result of the repair remains good at 1 year follow-up (Figs 1, 3). Histologic examination of an aortic wall specimen revealed idio- pathic medial necrosis.

Comment Rupture of an aneurysm of the ascending aorta into the right atrium is a rare event. Reports on this condition have described a relatively uniform symptomatology, comprising

Ann Thorac Surg 1991;51:125-7

CASE REPORT HENZE ET AL 127 ASCITES AFTER ANEURYSMAL RUPTURE

B Fig 3. Chest roentgenogram before (A) and 1 year after operation (B).

chest pain and, in some cases, dyspnea [l-lo]. Signs of increased right ventricular volume work, such as distention of the jugular veins, are also common, as is a systodiastolic murmur. A delay of several months between onset of symptoms and diagnosis is common. Mortality is high: 5 of the 12 reported patients. Two of these five deaths occurred before diagnosis, one after heart catheterization, and two

postoperatively. Six patients, including ours, survived after surgical correction, with reported follow-up of 6, 6, 8,9, 12, and 24 months. The fate of 1 patient was not reported. The possible mechanism for development of aorta-right atrial fistula is dissection into the aortoatrial space near a commis- sure of the aortic annulus, at which site the aortic media is not continuous with the annulus. From here the dissection enters the atrium. Diagnosis in previously reported cases was established from physical signs, cardiac catheterization, aortography [lo], and echocardiography [l, 5 , 111. In our case magnetic resonance imaging was useful in establishing the diagnosis.

Our patient differs from other reported cases in the development of intractable ascites without recurrence after operation. We are aware that the entire complication could have been prevented by early surgical treatment of the dissection or, better, by insertion of a composite graft at the time of aortic valve replacement.

References 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

Hurley DV, Nishimura RA, Schaff HV, Edwards WD. Aortic dissection with fistula to right atrium. Noninvasive diagnosis by two-dimensional and Doppler echocardiography with successful repair. J Thorac Cardiovasc Surg 1986;92:953-7. Dulake M, Ashfield R. Dissecting aneurysm of the aorta with rupture into the right atrium. Br Heart J 1964;26:862-4. Temple TE Jr, Anabtawi IN. Aortico-atrial shunt due to rupture of a dissecting aneurysm of the ascending aorta. J Thorac Cardiovasc Surg 1966;52:249-54. Page AJF, Yacoub MH, Sutton GC. Aorto-right atrial fistula. A rare complication of aortic dissection. Br Heart J 1973;35: 133840. Millward DK, Robinson NJ, Craige E. Dissecting aortic an- eurysm diagnosed by echocardiography in a patient with rupture of the aneurysm into the right atrium. Rare cause for continuous murmur. Am J Cardiol 1972;30:427-31. Buchler JR, da Cruz Forte AA. Aortic dissection aneurysm and aorta-right atrial fistula as a late complication of coronary surgery. Int J Cardiol 1983;4:1924. Nicod P, Firth BG, Peshock RM, Gaffney FA, Hillis LD. Rupture of dissecting aortic aneurysm into the right atrium. Clinical and echocardiographic recognition. Am Heart J 1984; 107:127&8. Timmis AD, Rosin MD, Ramtoola S. Localized aortic dissec- tion with rupture into the right atrium. Diagnosis by com- puted tomography and cardiac catheterization. Am J Cardiol 1985;56:204-5. Crittenden MD, Maitland A, Canepa-Anson R, Salerno TA. Aorta-right atrial fistula: an unusual complication of ascend- ing aortic dissection. Can J Surg 1987;30:380-1. Holmes EC, Brawley RK, Fortuin NJ, White RI Jr. Rupture of dissecting aneurysm of thoracic aorta into the right heart chambers. J Thorac Cardiovasc Surg 1974;68:6114. Berman AD, Come PC, Riley MF, et al. Two-dimensional and Doppler echocardiographic diagnosis of an aortic to right atrial fistula complicating aortic dissection. J Am Coll Cardiol 1987;9:22&30.