Introduction: Fistulas between the aorta and the left atrium are very rare. They are usually a complication of aortic root abscess formation caused by aortic valve endocarditis, but also of paravalvular abcess, aortic valve replacement, and aortic dissection (1).

Case presentation: We present a case of a 69-year-old woman who was referred to our Clinic for transesophageal echocardiography evaluation (TEE) of a suspected aorto-left atrial communication. Eight years earlier, she had undergone aortic valve replacement with a 21-mm St. Jude Medical mechanical aortic valve because of aortic stenosis. Three years later, she presented with effort intolerance and dyspnea. These symptoms aggravated over the years. Transthoracic echocardiography performed at the beginning of 2015 demonstrated the normal position and function of a mechanical aortic valve with suspected aorto-left atrial communication. A three-dimensional TEE performed in our Clinic revealed a fistula between the noncoronary sinus of the aorta and left atrium with a shunt through it. The left ventricle function was preserved.

Conclusion: Although very rare, aorto-left atrial fistulas are very interesting echocardiographic findings which may be presented with heart failure symptoms. Echocardiography, especially TEE, is crucial in confirming the diagnosis. The surgical closure of aorto-left atrial fistulas is the standard treatment in symptomatic patients. The percutaneous closure of aorto-left atrial fistulas with an Amplatzer-type device may be performed in cases when the anatomy is favorable (2).