Percutaneous closure of complex paravalvular aortic root pseudoaneurysm and aorta-cavitary fistulas

Abstract

Native aortic valve or its prosthetic valve endocarditis can extend to the adjacent periannular areas and erode into nearby cardiac chambers, leading to pseudoaneurysm and aorta-cavitary fistulas respectively. The later usually leads to acute cardiac failure and hemodynamic instability requiring an urgent surgical intervention. However rarely this might pass unnoticed and the patient might present later with cardiac murmur. Percutaneous device closure of aortic pseudoaneurysm, ruptured sinus of Valsalva aneurysm, aorta-pulmonary window, paravalvular leaks, and aorta-cavitary fistula have been reported. We present a 59-year-old female who developed a large aortic root pseudoaneurysm with biventricular communication aorta-cavitary fistulas presenting late following aortic prosthetic valve endocarditis. She underwent successful percutaneous device closure of her pseudoaneurysm and aorta-cavitary fistulas using two Amplatzer Duct Occluders. This case illustrates a challenging combination of aortic root pseudoaneurysm and biventricular aorta-cavitary fistulas that was successfully treated with percutaneous procedure.

Keywords: Aorta-cavitary fistula; Device closure; Endocarditis; Pseudoaneurysm.

Fig. 1

Transesophageal echocardiogram (TEE) showing a large aortic root pseudoaneurysm involving right coronary cusp extending from aortic valve prosthesis in a patient with aortic valve prosthetic endocarditis (A, arrowheads). Note pseudoaneurysm to biventricular fistulous connection (B, arrowheads) with color Doppler flow across these fistulous tracts (C, arrowheads). LA, Left atrium; RA, Right atrium; LV, Left ventricle; RV, Right ventricle; AO, Aorta; AVP, Aortic valve prosthesis.

Fig. 2

Computed Tomography scan of chest demonstrating a large aortic root paravalvular pseudoaneurysm in a patient with aortic valve prosthetic endocarditis (A, arrowheads). Note pseudoaneurysm to left and right ventricular fistula connections (B and C, arrowheads, respectively).

Fig. 3

Aortogram demonstrates paraprosthetic kidney shaped pseudoaneurysm with fistulous connection to left ventricle (A, arrowheads) and right ventricle (B, right arrowheads) in a patient with aortic valve prosthetic endocarditis. (C) Fluoroscopy demonstrating balloon sizing of the pseudoaneurysm neck measuring 5 mm and the PA to left ventricular fistula connection measuring 10 mm. LV, Left ventricle; RV, Right ventricle; PA, pseudoaneurysm.

Fig. 4

Fluroscopy showing the deployment of Amplatzer Duct Occluder I (ADO I) aortic disc in the paravalvular pseudoaneurysm and the pulmonary disc into the right ventricle (A, arrowheads). (B) Control aortography showing complete occlusion of the aortic paravalvular pseudoaneurysm to right ventricular as well as left ventricular fistula connections. (C) A second ADO I device (C, right arrowheads) as advanced from right femoral artery and the aortic disc was deployed in the pseudoaneurysm interlocking the first device and the pulmonary disc was deployed into the pseudoaneurysm-ascending aorta connection.

Fig. 5

(A) Fluoroscopy demonstrating released two Amplatzer Duct Occluder I (ADO I) devices inside a paravalvular pseudoaneurysm with biventricular fistulas occluding both the fistulous tracts. (B) TEE demonstrating both the ADO I devices inside the paravalvular pseudoaneurysm (arrowheads) thus excluding the pseudoaneurysm as well as the biventricular fistula connections. LA, Left atrium; RA, Right atrium; AO, Aorta.