Author + information
- Vakhtang Tchantchaleishvili, MD∗,
- Victor Becerra-Gonzales, MD†,‡,
- Genaro Fernandez, MD†,
- Hanna Z. Mieszczanska, MD†,
- Babak S. Jahromi, MD, PhD§ and
- Christopher J. Cove, MD†∗ ()
- ∗Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, New York
- †Division of Cardiology, University of Rochester Medical Center, Rochester, New York
- ‡Universidad Nacional Mayor de San Marcos, Lima, Peru
- §Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York
- ↵∗Reprint requests and correspondence:
Dr. Christopher J. Cove, Division of Cardiology, University of Rochester Medical Center, School of Medicine and Dentistry, 601 Elmwood Avenue, Box 679, Rochester, New York 14642.
A 30-year-old woman with worsening heart failure (New York Heart Association functional class III) was found to have an ∼3-cm arteriovenous malformation (AVM) in the anteriolateral left ventricle wall (Figure 1A), supplied by obtuse marginal (OM) branches (Figure 2A, Online Video 1). OM1 was embolized at the level of the aneurysm. More proximal coil placement was not performed to avoid infarcting normal myocardium. Supply from a small branch of the larger OM2 was not embolized given its small size. The procedure failed because of new collateralization from this branch and recanalization around the coils in OM1 (Figure 2B, Online Video 2), and the patient’s clinical status did not improve. Eight weeks later, the AVM was embolized with Onyx (Covidien, Mansfield, Massachusetts) using a triaxial system consisting of a 6-F extra back-up 3.5 guiding catheter (Medtronic, Minneapolis, Minnesota), 0.38 distal access intermediate catheter (Concentric Medical, Fremont, California), and an Echelon-10 microcatheter (Covidien). Embolization from OM1 (proximal to previously placed coils) failed to penetrate the AVM, whereas embolization from the OM2 branch inferior to the AVM completely casted the AVM (Figure 2C, Online Video 3), resulting in an angiographic cure (Figure 2C, Online Video 4). Follow-up cardiac magnetic resonance imaging confirmed shrinkage of the AVM with no residual flow (Figure 1B). The patient’s symptoms resolved, and during 43 months of follow-up, no recurrence was observed clinically or by serial echocardiograms and cardiac magnetic resonance imaging.
Cardiac AVMs are exceedingly rare and can have fatal outcomes secondary to intractable heart failure or arrhythmias (1,2). Onyx is a liquid embolic agent different from prior cyanoacrylate-based “glues” and has been successfully used in brain AVMs (3). Onyx allows slow, controlled embolization, with multiple interrupted injections finding new AVM compartments, and has much less adherence to catheter tips, even when casted. To our knowledge, this is the first successful percutaneous treatment of a cardiac AVM using the Onyx embolization system.
For supplemental videos and their legends, please see the online version of this article.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2015 American College of Cardiology Foundation