Commentary: There is nothing like looking, if you want to find something.

Michele Di Mauro, MD, PhD, MSc (MDM), Giorgia Bonalumi, MD (GB), Antonio M. Calafiore, MD (AMC), and Alessandro Parolari, MD (AP)

Aorta-to-right atrial fistula is a rare but very serious complication of aortic dissection. We need to search for it before starting the operation.

See Article page 1.

Aorta-to-right atrial fistula is a rare but very serious complication of infective endocarditis and predicts a greater mortality or a congenital condition also known as aorta-right atrial tunnel. Aorta-to-right atrial fistulas as a complication of type A aortic dissection have been described as anecdotal cases since 1973.3, 4, 5, 6 All these cases, as well as the case reported by Kitada and colleagues, demonstrate the close anatomic relationship between the aortic root and the right atrium. Anatomically, the right atrium adjoins the aorta in the area between the noncoronary and right coronary cusps. In 70% of cases, the aorta-right atrial fistula originates in the noncoronary cusp.

The peculiarity of this case lies in the fact that from the inside of the aorta, the origin of the fistula was not available because the lesion was at the level of the adventitia and therefore it was the false and not the true lumen to communicate with the right atrium. This led surgeons to close the fistula using horizontal mattress sutures from the right atrium to the aorta, through around the fistula, reinforcing with 2 patches, Dacron on the right atrial side and autologous pericardium inside the aorta. The take-home message of this case report can be summarized with a quote by J.R.R. Tolkien: “There is nothing like looking, if you want to find something. You certainly usually find something, if you look, but it is not always quite the something you were after.”