Author + information
- Received September 6, 2018
- Revision received October 19, 2018
- Accepted October 23, 2018
- Published online January 7, 2019.
- Ali Z. Zgheib, MD,
- Joseph Roumi, MD,
- Shareef Mansour, MD,
- Walid Gharzuddine, MD and
- Fadi J. Sawaya, MD∗ ()
- ↵∗Address for correspondence:
Dr. Fadi Sawaya, American University of Beirut Medical Center, Cairo Street, Beirut 75010, Lebanon.
We report the case of a 61-year-old man with a history of type A aortic dissection who underwent emergency repair with a Dacron graft in 2015, followed 1 year later by mechanical aortic valve replacement for severe aortic regurgitation, who presented to our institution with multiple admissions for right-sided failure: recurrent ascites and leg edema requiring intravenous diuresis and paracentesis. Transthoracic echocardiography showed a normal left ventricular ejection fraction and moderate right ventricular dilation (a new finding). The aortic mechanical valve showed normal function, with a visible shunt between the proximal ascending aorta and the right atrium (Online Video 1). In addition, there was moderate tricuspid regurgitation. Transesophageal echocardiography showed a large shunt by color Doppler originating from the ascending aorta (between the right coronary and noncoronary sinuses) consistent with a sizable aortic–right atrial fistula (Online Video 2). The decision was made to perform percutaneous aortic–to–right atrial fistula closure. Cardiac computed tomography performed for procedural planning showed a maximal fistula diameter of 8.7 mm, with a neck and body similar in morphology to a patent ductus arteriosus (Figure 1).
The procedure was performed under general anesthesia and transesophageal echocardiographic guidance using a 6-F catheter through a right radial approach. Aortography showed a fistula between the noncoronary and right coronary sinuses into the right atrium (Online Video 3). The fistula was crossed with a Terumo stiff wire using a JR 4.0 5-F catheter from the arterial side (Online Video 4). The Terumo wire was snared into the right femoral vein, and an arteriovenous rail was formed (Online Video 5). A 9-F delivery sheath was introduced through the right femoral vein, and a 14/12-mm Amplatzer Duct Occluder (St. Jude Medical, St. Paul, Minnesota) was deployed across the fistula from the venous side (Online Videos 6 and 7). We chose an Amplatzer Duct Occluder because the fistula resembled a patent ductus arteriosus, and deployment from the venous side allowed us to position the aortic disc as close to the wall as possible far from the discs (Online Video 8). Transesophageal echocardiography showed successful closure with trivial residual shunt (Online Video 9). Eight months since fistula closure, the patient has had complete resolution of symptoms, with no heart failure readmissions, New York Heart Association functional class I symptoms, and normalization of right ventricular size.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received September 6, 2018.
- Revision received October 19, 2018.
- Accepted October 23, 2018.
- 2019 American College of Cardiology Foundation