Multimodality Imaging and Percutaneous Closure of Right Sinus of Valsalva to Right Ventricular Outflow Tract Fistula After Transcatheter Aortic Valve Replacement

J INVASIVE CARDIOL 2019;31(7):E227-E228.

Key words: computed tomography, fistula, transesophageal echocardiogram

Although transcatheter aortic valve replacement (TAVR) is a safe procedure, complications can occur. The most alarming one is annular rupture, which is unpredictable and can be life threatening, and occurs in about 1% of TAVR patients. Annular rupture can be caused by valve over-sizing, re-ballooning for paravalvular regurgitation, or even with nominal ballooning when there is a large amount of nodular calcification of the leaflets, annulus, left ventricular outflow tract (LVOT), or sinus of Valsalva adjacent to the annulus. The standard of care is medical observation for small defects and high-risk surgery for larger defects.

A 90-year-old male with multiple medical comorbidities was admitted with critical aortic stenosis. He underwent TAVR with a 26 mm Sapien S3 valve (Edwards Lifesciences) with nominal inflation. Postinflation echocardiogram revealed a 0.7 x 0.4 cm fistula between the aortic root, right sinus of Valsalva region to the right ventricular outflow tract (RVOT) with moderate dilation of the right ventricle. He remained stable over the next 48 hours and was discharged home. After 4 days, he was readmitted with shortness of breath. His blood pressure was 120/20 mm Hg. Blood tests revealed increased serum lactate dehydrogenase level and reticulocyte count with decreased haptoglobin levels, suggestive of hemolysis. As the patient and family did not want open-heart surgery, a trial of percutaneous closure was decided. Shunt oximetry confirmed a pulmonary to systemic flow ratio of 2 at the RVOT level. Using a 5 Fr hydrophilic multipurpose catheter, an angled Glidewire (Terumo) was passed carefully through the serpiginous track into the RVOT and was placed in the right upper lobe of the pulmonary artery. Thereafter, the wire was removed and an 8.0 x 13.5 mm Amplatzer Vascular Plug 4 (St. Jude Medical) was passed and deployed across the fistula. Postprocedure transesophageal echocardiography showed minimal flow across the fistulous tract. Over the next 24 hours, the patient’s blood pressure improved to 135/58 mm Hg and he was discharged home.

From the Heart and Vascular Institute, Carle Foundation Hospital, Urbana, Illinois.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted December 10, 2018.

Address for correspondence: Sanjay S. Mehta, MD, FACC, FSCAI, Assistant Professor University of Illinois at Urbana Champaign, Heart and Vascular Institute, Carle Foundation Hospital, Urbana, IL 61801. Email: Sanjay.Mehta@Carle.com