Left Ventricle to Left Atrial Fistula Caused by Perforated Perivalvular Abscess

Oetama S1, Soesanto AM1

1
Department of Cardiology and Vascular Medicine, Faculty of Medicine Universitas Indonesia,
National Cardiovascular Center Harapan Kita

Background
Perivalvular abscess is a perilous intracardiac infection with high mortality and morbidity rate.
Abscess perforation may lead to fistula and complicates the patient’s management.

Case Summary
A 35-year-old man came to our echocardiography polyclinic with recurrent episodes of dyspnea
on effort and lower limb swelling since 6 years ago. His vital signs were normal except for mild
tachycardia. His auscultation revealed loud pansystolic murmur on left lower sternal border and
apex. Transthoracic echocardiography showed dilatation of all cardiac chambers with D-shaped
left ventricle (LV) and reduced ejection fraction. There was eccentric LV hypertrophy and
reduced right ventricular systolic function. A third chamber between LV and left atrium (LA)
was visualized from apical 4 chamber view. Color Doppler revealed severe mitral and tricuspid
regurgitation with concentric jet. Apical 5 chamber view enhanced visualization of the cavity
with eccentric jet to the LA from laterobasal LV fistula. Additionally, there was minimal
circumferential pericardial effusion with no signs of cardiac tamponade. The patient was planned
for infective endocarditis workup and surgical valves repair with debridement.

Discussion
Other than vegetation, perivalvular abscess is the second major echocardiographic criterion for
infective endocarditis. Perforated abscess appears as interruption of endocardial tissue continuity
traversed by color Doppler flow while fistula is a communication between two neighboring
cavities through a perforation. In our case the connection is between LV and LA, worsening the
already severe mitral regurgitation with extra flow from the fistula. Elective surgery was planned
due to no sign of active infection.

Keywords
Perivalvular abscess, fistula, mitral regurgitation