Understanding an aorto-atrial fistula in a patient with heart failure

A 37-year-old previously healthy man presented with progressive dyspnea, peripheral edema, and weight gain over four months.Examination revealed a continuous heart murmur with pulmonary and peripheral congestion.NT-proBNP was markedly elevated despite high-dose furosemide therapy.Transthoracic and three-dimensional transesophageal echocardiography (3D TOE) identified an aortoatrial fistula from the non-coronary sinus of Valsalva to the right atrium (Fig. 1a, yellow arrows; Supplementary Videos 1-4).The fistulous jet coursed parallel to the tricuspid annulus, impinging eccentrically on the right atrial wall.A concomitant 16-mm ostium secundum atrial septal defect produced a significant leftto-right shunt (Fig. 1a, green arrow; Supplementary Videos 2-3).No evidence of endocarditis was found, and the fistula was considered congenital.The patient underwent successful surgical repair of both defects (Fig. 1b, yellow arrow showing the fistulous pathway) and was discharged uneventfully.This rare case highlights the crucial role of multimodality imaging in guiding tailored surgical planning.