DISCUSSION
In this case, we presented a patient with congenital aortic-right atrium
fistula that we detected in adulthood and which we closed
percutaneously. According to our literature review, it is the second
ARAF case that is congenital and detected in adulthood and closed
percutaneously. The first case of ARAF was successfully closed by Patra
S. et al (2) at the age of 22 with ARAF Amplatzer Vascular Plug II (St.
Jude Medical, St. Paul, Minnesota, USA) that opened the aorta from the
right coronary sinus through a giant aneurysm chamber into the right
atrium.
The presence of blood flow between the aorta and atrium is a rare but
complex pathological condition also known as aortic-atrial fistula
(AAF). AAF can be congenital or acquired (infective endocarditis,
trauma, aortic dissection, a complication of cardiac surgery, etc.). The
exact incidence is currently unknown as AAF has not been extensively
studied. There is also a lack of information regarding various aspects
of AAF such as diagnostic strategies and management options. The
embryological background and cause of congenital ARAF are unclear.
Gajjar et al. (3) argue that the probable cause of this condition is a
congenital deficiency of the elastic lamina in the media layer of the
aorta, and as a result, due to high aortic pressure, the defective area
in the aortic wall creates an extracardiac tunnel. It causes gradual
enlargement and rupture of the right atrium due to the anatomical
proximity and low filling pressure.
In the systematic review conducted by Jainandunsing JS et al.(1), a
literature review was conducted and 136 AAF patients, including all age
groups, were examined. ARAF was the most common with 63.2%. The
incidence of congenital ARAF was 9.6%. ARAF was closed surgically in
73.5% and percutaneously in 10.3%. Amplatzer device was used in 71.4%
of percutaneous closures. As a treatment approach in this review; If
small ARAFs are asymptomatic, close monitoring with diuretic therapy and
active closure of the fistula should be considered if the clinical
condition worsens. Large ARAF requires emergency closure by a
percutaneous or surgical approach. Spontaneous closure of ARAF is very
rare and conservative treatment should not be recommended in cases with
large fistulas or clinical symptoms. Surgery and percutaneous closure
had similar results.
In our case, closure was decided because the patient was symptomatic.
Percutaneous intervention was preferred to surgery, as the fistula has a
distinct origin and a narrow terminal ending in the right atrium.