Acquired Left Ventricular-Right Atrial Communication and Severe Aortic Valve Regurgitation Caused by Infective Endocarditis

Case Report

A 21-year-old woman visited a referring hospital with fatigue and shortness of breath in October 2001. A harsh and continuous cardiac murmur was detected for the first time. The patient had been given two antibacterial agents over the previous week to treat persistent fever. The chest X‐ray showed pulmonary edema and an increased cardiothoracic ratio of 58 %. Echocardiography revealed severe aortic regurgitation with a posteriorly-directed jet ([Fig. 1 A]). In addition, an intracardiac shunt from the left ventricle (LV) to the right atrium (RA) was detected ([Fig. 1 B]). Upon transfer to our institution, the laboratory results showed a serum level of C-reactive protein (CRP) of 2.5 mg/ml and a normal white blood cell count. Trans-esophageal echocardiography (TEE) demonstrated a mobile nodule in the RA ([Fig. 1 C]), consistent with endocarditic vegetation. The patient was immediately taken to surgery to treat her rapid descent into cardiorespiratory failure.

Fig. 1 A to C Echocardiography demonstrates severe aortic valve regurgitation posteriorly (A: arrow) and shunt from the LV to the RA (B). Trans-esophageal echocardiography demonstrates a shaggy moving nodule in the RA (C).

External inspection revealed a tense, undilated RA with a palpable thrill. After aortic cross-clamping, an aortotomy was performed. The aortic cusps were not thickened and no vegetation was observed. The right coronary cusp had a perforation of 6 mm in diameter ([Fig. 2 A]), causing severe aortic regurgitation. Next, a right atriotomy was performed and a 4-mm perforation of the atrioventricular septum was found just above the tricuspid annulus, surrounded by small vegetation ([Fig. 2 B]). The adjacent atrioventricular septal tissue was fragile, while the tricuspid valve was intact. After the vegetation was gently excised, a small Nelaton tube was inserted through the perforation, confirming the communication between the LV and RA ([Fig. 3 A] and [B]). This communication channel was closed with a PTFE patch (Kono Seisakusho, Chiba, Japan) covered by autologous pericardium on its left ventricular aspect. The patches were oversized (2 cm in diameter) so that they were larger than the communication in order to avoid placing stitches on the more proximal area of the conduction system. Three stitches were placed in the aortic annulus and simultaneously utilized to secure the aortic prosthesis in place. An additional autologous pericardial patch was placed on the right atrial side to reinforce the patch closure. That patch was similarly oversized (3 × 1.5 cm). The stitches to secure it in place were placed on the tricuspid annulus and just near the coronary sinus, thus avoiding the Koch's triangle. Aortic valve replacement was accomplished using a 21-mm Carpentier-Edwards Perimount bioprosthetic valve (Edwards Lifesciences, Irvine, CA, USA) in compliance with the patient's wishes.

Fig. 2 A and B Intraoperative photographs demonstrating the perforated right coronary cusp (A: arrow) and the vegetation in the RA (B: arrow).

Fig. 3 A to C The Nelaton tube inserted into the RA reaches the LV through the communication (arrow) (A and B). C Postoperative echocardiogram demonstrating successfully placed patches and the bioprosthetic valve (arrow).

The pulmonary edema subsided soon after the surgery and the patient was extubated on the first postoperative day. All cultures were negative and CRP levels returned to normal values. Two antibacterial drugs were administered intravenously for a month. A postoperative echocardiography one week after surgery showed no residual LV‐RA shunt ([Fig. 3 C]). The patient persisted in a normal sinus rhythm and had an uneventful postoperative course.

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