The Curious Discovery of a New Intracavitary Right Atrial Continuous Doppler Flow Signal; A Diagnostic and Management Dilemma
Document Type
Article
Abstract
Background: Discovery of fistulas post cardiac surgery is unusual and their management is often challenging. Hemodynamic effects and symptoms stemming from abnormal flow can help guide treatment decisions, but confounding factors should also be considered.
Case: A 74-year-old male extreme athlete whose exercise routine included long distance rowing and mountain biking underwent bioprosthetic aortic and mitral valve replacement for asymptomatic chronic severe aortic regurgitation (AR) associated with a dilated left ventricle with reduced ejection fraction (45%), moderate functional mitral regurgitation and a mildly dilated right ventricle (RV) with reduced systolic function. A post op transthoracic echocardiogram showed a new right atrial (RA) cavity continuous Doppler signal and worsening RV dilation. Cardiac catheterization revealed a new small RV marginal branch to RA fistula. There was with no significant step up in O2 saturation from the vena cava to the RA and the Qp:Qs was 1.
Decision-making: This case was challenging since no clear etiology of RV dilatation and dysfunction was apparent in this asymptomatic, life long athlete. Resolution of the AR and augmentation of diastolic BP may have resulted in enhanced coronary artery perfusion pressure uncovering the post op coronary artery to RA fistula. The etiology for the progressive post op RV dilation remained uncertain. The coronary fistula volume was too small to account for this finding. Chronic severe AR may have been a contributing factor and long term extreme endurance training has been associated with right heart pathology as well. A heart team approach was utilized in this case and continued observation with close follow up was recommended.
Conclusion: This case posed a management dilemma in an asymptomatic, extreme athlete with worsening RV dilatation in the setting of a small RV marginal branch to RA fistula after AVR and MVR. Angiographic and oxymetric analysis resolved the curious echo Doppler finding and highlighted the importance of diastolic BP on coronary artery perfusion. The pre op detection of mild RV dysfunction in patients with chronic severe AR and functional MR should be considered as a marker for post op worsening RV function.
DOI
10.1016/S0735-1097(21)03502-6
Publication Date
5-11-2021
Recommended Citation
Tariq U, Satuluri P, Vadhar S, Sheikh T, Gupta R, Singh S, Feldman B, Singer R. THE CURIOUS DISCOVERY OF A NEW INTRACAVITARY RIGHT ATRIAL CONTINUOUS DOPPLER FLOW SIGNAL; A DIAGNOSTIC AND MANAGEMENT DILEMMA. Journal of the American College of Cardiology. 2021 May 11;77(18_Supplement_1):2146-.