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Aortocardiac fistula with aortic valve injury from penetrating trauma.

A patient with a delayed aorto-right ventricular fistula and aortic valve injury after penetrating trauma is reported, and 17 similar additional cases from the literature reviewed. By examining the aortic root of adults with normal cardiac anatomy at autopsy, we defined the target area for these injuries as a 2 X 2 cm contact surface between the aorta above the right coronary cusp and the right ventricular outflow tract below the pulmonary valve. Five of the 18 patients required emergency exploration due to hemodynamic instability. Life-threatening sequelae (hemorrhage and cardiac tamponade) result from the external injury rather than the intracardiac component. Intracardiac damage is most commonly manifested as the delayed recognition of a cardiac murmur and some degree of congestive heart failure, and when these appear one must suspect intracardiac trauma. We recommend cardiac catheterization and elective repair, maintaining control of both ends of the intracardiac fistula with bolstered suture. Aortic valve injury can often be primarily repaired. Patients with combination aortic valve and aortocardiac fistula injuries, more so than those with a single intracardiac lesion, fail with nonoperative management. Of the 18 patients, 17 underwent surgery. One of these died: the others did well during short-term followup (less than 1 year).