Successful percutaneous closure of aortic root-to-right ventricle fistula after transcatheter aortic valve implantation: a valuable option in high-risk surgical patients

Abstract

Background: Aortic-to-right ventricle (ARV) fistula is an uncommon complication of transcatheter aortic valve implantation (TAVI). Even though surgical closure is usually the treatment of choice in such communications, percutaneous treatment options are valuable alternatives for these high-risk surgical patients.

Case summary: In this article, we present the percutaneous closure of an ARV fistula after TAVI, in a highly symptomatic patient with recurrent episodes of heart failure decompensation with worsening right ventricular function, who failed conservative medical treatment and was deemed inoperable. Successful closure of the fistula with the use of the Amplatzer atrial septal occluder was performed 6 months post-TAVI, under general anaesthesia and transoesophageal echocardiography (TOE). A detailed multi-modality imaging pre-procedural planning was performed utilizing 4D cardiac computed tomography and echocardiography. The patient has remained asymptomatic and in good health 5 months after the ARV fistula closure, with marked improvement in his clinical picture and echocardiographic parameters.

Discussion: Aortic-to-right ventricle fistulas with significant shunt post-TAVI could lead to biventricular failure and are associated with increased mortality if left untreated. This case demonstrates that TOE-guided percutaneous closure of a TAVI-related ARV fistula, although technically challenging, is feasible, and can be a valuable option for the treatment of symptomatic high-risk surgical patients.

Keywords: Aortic valve; Case report; Complication; Shunt; TAVI.

Figure 1

Transthoracic echocardiogram with colour flow Doppler showing a shunt between the aortic root and the right ventricle.

Figure 2

Four-dimensional cardiac computed tomography scan showing a communication between the aortic root and the right ventricle behind the transcatheter aortic valve implantation struts.