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A sinus of valsalva aneurysm (SVA) is an asymmetrical dilatation of the aortic root located between the aortic valve anulus and the sino-tubular junction. Congenital weakness of the elastic lamina in the aortic media layer or trauma and infection as acquired events are the most principal causes of SVA. Presentation may be acute when rupture has occurred or SVA may be discovered fortuitously on echocardiography or CT scan when patients are examined because of unspecific chest pains, dyspnea or arrhythmias. Although endovascular treatment has been performed successfully in individual cases, surgical closure of the aneurysm aiming at preservation of the aortic valve whenever possible is the established procedure. This short report emphasizes the fact that individual treatment is required when SVA need to be operated, depending on the presentation, the location and the size of the finding. Surgery may consist of simple patch closure, bilateral tunnel closure (entry and exit) or more radical operation like Bentall in case the whole aortic root should be addressed. Overall results are excellent, independently of the clinical presentation (acute or elective) with a mortality approaching zero.

UNASSIGNED: Sinus of valsalva aneurysms (SOVAs) are infrequent findings and generally diagnosed incidentally. A SOVA may be at risk for rupture, which would lead to an aorto-cardiac shunt. These patients present similarly to decompensated heart failure.
UNASSIGNED: We present a case of a 44-year-old female with a ruptured non-coronary SOVA diagnosed by echocardiogram during evaluation for exertional dyspnoea. A trans-oesophageal echocardiogram (TEE) revealed a 2.1 cm non-coronary SOVA with windsock communication to the right atrium. The patient refused surgery, and two years later, presented with florid right heart failure with preserved left ventricular function. The right ventricle was severely dilated and hypokinetic with right atrial enlargement. After finally agreeing to surgery, a pre-operative catheterization revealed non-obstructive coronaries and a significant left to right shunt with elevated pulmonary pressure. The patient had suboptimal response to diuretic therapy and was sent for successful repair of the aneurysm with the closure of the aorto-atrial fistula via bovine pericardial patch and resolution of the left to right shunt as demonstrated by intra-operative TEE. Her right-sided heart failure symptoms subsequently resolved.
UNASSIGNED: SOVA is a rare finding but should still be considered in the differential in young and middle-aged patients with symptoms of acute heart failure, hemodynamic compromise, and a new continuous heart murmur. Early surgical repair is highly recommended to prevent acute and long-term complications.

Our case highlights an atypical presentation of aortic valve endocarditis after initial presentation with endophthalmitis. This case demonstrates the rapidity of evolution of aortic valve endocarditis through sequential, multimodal imaging, and features the importance of a multidisciplinary approach required for the management of complicated aortic valve endocarditis. A male in his mid-thirties was admitted to the hospital with left endophthalmitis and diabetic ketoacidosis. He was found to have aortic valve endocarditis and severe aortic insufficiency, which progressed to aortic root pseudoaneurysm and subsequently to aorto-atrial fistula in less than 72 hours, as demonstrated by consecutive multimodality imaging studies. After extensive surgical repair, post-operative recovery, and rehabilitation, he was discharged home with a good functional outcome. Sequential and multimodal imaging can be beneficial in diagnosing paravalvular infection early in its evolution, which is crucial for decision-making regarding medical and surgical treatment strategies.

UNASSIGNED: Infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI) occurs in up to 1.5% of patients within the first year. The development of an aorto-atrial fistula (AAF) is a rare but problematic complication of IE, which can be confirmed with transoesophageal echocardiography (TOE). We present an exceptional case of occluding an aorto-left atrial fistula only diagnosed with intraprocedural TOE during a subsequent procedure of MitraClip implantation.
UNASSIGNED: A 79-year-old symptomatic male patient with multiple comorbidities was referred due to severe mitral regurgitation (MR). He has had prior TAVI which was complicated with streptococcal IE for which he had received prolonged antibacterial therapy. Transthoracic echocardiography (TTE) revealed severe MR. The patient was accepted for a MitraClip procedure by the heart team. Intra-procedural TOE revealed also a significant continuous shunt through an AAF which was likely caused by the endocarditis. The strategy was therefore defined as to occlude the fistula with an Amplatzer Vascular Plug II 12 mm. The plug was released in the fistula leaving an insignificant residual shunt. After the transseptal puncture one MitraClip XTR was implanted, reducing the MR to mild. After the procedure, the patient\'s general clinical condition improved without signs of haemolysis. The pre-discharge TTE confirmed trace residual shunt, mild residual MR and mild paravalvular leakage.
UNASSIGNED: Our case illustrates a complex transcatheter structural heart intervention with improvised procedural strategies based on the intra-procedural TOE findings. We conclude that the pre-procedural TOE needs to be comprehensive rather than exclusive, particularly in the context of bioprosthesis-related endocarditis.

A 35-year-old woman without any history of congenital heart disease presented to our clinic with dyspnea on exertion. Transthoracic echocardiogram (TTE) showed an eccentric tricuspid regurgitant jet and increased right ventricular systolic pressure. Transesophageal echocardiogram (TEE) revealed a sinus of Valsalva aneurysm (SVA) arising from the noncoronary sinus that ruptured into the right atrium, leading to the formation of an aorto-right atrial fistula. Right heart catheterization confirmed left to right shunt. The fistulous tract was resected, and the aneurysm repaired surgically. The patient made a good recovery.

A ruptured sinus of Valsalva aneurysm as a cause of aorto-atrial fistula is very rare. We present the case of a 53-year-old female who presented with symptoms of acute heart failure and suspicion of an aorto-atrial fistula found on a transthoracic echocardiogram, which was confirmed on transesophageal echocardiography. A coronary angiogram showed normal coronary arteries but confirmed the right aorto-atrial fistula on aortogram. She underwent successful surgical repair of the fistula. Her postoperative echocardiogram showed a normal right atrium and right ventricle with no shunt. A ruptured sinus of Valsalva aneurysm is a devastating event and presents as acute heart failure. Prompt diagnosis and surgical repair is necessary to prevent mortality.
CONCLUSIONS: A ruptured sinus of Valsalva aneurysm causing an aorto-atrial fistula can present as acute heart failure.A transthoracic echocardiogram can identify the presence and location of a sinus of Valsalva aneurysm, while a transesophageal echocardiogram can recognize fistulous tract formation. Cardiac magnetic resonance imaging and computed tomography can confirm or better categorize echocardiographic findings.The management of an aorto-atrial fistula is surgical intervention, involving a patch repair.

Aorto-cardiac fistulae are a rare but increasingly reported entity, and data are scarce.
The authors performed a systematic review of ACFs to characterize the underlying etiology, clinical presentation, and compare outcomes of treatment strategies.
3,733 publications were identified in the search. Of those, 292 studies including 300 patients were included. Etiology of ACFs was 38% iatrogenic, 25% infectious, 14% traumatic, and 15% due to other causes. Most patients (74%) presented with heart failure. Common locations were aortic-right atrium (37%), and aortic-pulmonary artery (25%). The majority of patients (71%) were treated surgically, while 13% were treated percutaneously, and 16% were treated conservatively. Patients who were managed conservatively had a higher mortality than those treated with invasive closure (53% vs. 12% vs. 3%, p = <0.00001).
This systematic review sheds light on this highly morbid condition. Once recognized, fistula closure appears to be superior to conservative management.

Aorto-atrial fistula is a rare complication of prosthetic aortic valve replacement and most of them have been diagnosed as a late complication. We present a case of this unusual complication after aortic valve replacement which was diagnosed intraoperatively and this potentially disastrous complication was corrected promptly. Early recognition and diagnosis of this rare surgical complication with intraoperative transoesophageal echocardiography (TEE) is imperative for prompt surgical repair of this lethal defect.

Aorto-atrial fistulas are rare complications of aortic valve replacement. We report a case of a post-aortic valve replacement aorto-atrial fistula that was closed percutaneously with an Amplatz Ductal Occluder-II device.