Author + information
- Received May 17, 2013
- Revision received July 1, 2013
- Accepted July 3, 2013
- Published online March 1, 2014.
- Todd L. Kiefer, MD∗∗ (, )
- John P. Vavalle, MD∗,
- Adam Devore, MD∗,
- Chetan B. Patel, MD∗,
- Joseph Rogers, MD∗,
- Carmelo Milano, MD†,
- Thomas R. Gehrig, MD∗ and
- J. Kevin Harrison, MD∗
- ∗Division of Cardiology, Duke University Medical Center, Durham, North Carolina
- †Division of Cardiac Surgery, Duke University Medical Center, Durham, North Carolina
- ↵∗Reprint requests and correspondence:
Dr. Todd Kiefer, Box 3126 DUMC, Duke University Medical Center, Durham, North Carolina 27710.
A 60-year-old man with end-stage heart failure underwent orthotopic heart transplantation. Before transplantation, he had elevated pulmonary artery (PA) pressures (60/17 mm Hg, mean PA 35 mm Hg) and pulmonary vascular resistance (PVR) (6.6 Wood units).
Following transplantation, he initially did well, with normalization of PA pressures (27/13 mm Hg, mean PA 20 mm Hg). Several months later, however, he developed overt right heart failure. Invasive hemodynamic evaluation demonstrated severe pulmonary hypertension (92/51 mm Hg, mean PA 66 mm Hg) with a PVR of 10 Wood units. There was no evidence of allograft rejection or pulmonary embolism. Transthoracic echocardiogram demonstrated right ventricular (RV) systolic dysfunction and enlargement. Color flow Doppler imaging demonstrated continuous flow from the ascending aorta into the main PA. The anatomy was confirmed by computed tomographic angiographic imaging (Fig. 1).
Oximetry measured a modest left-to-right shunt at the PA level and no right-to-left shunt (Qp/Qs shunt fraction = 1.2:1). Percutaneous closure of the aorta-to-PA fistula was recommended.
A 6-F Judkins Left 3.5 (Cordis Inc., Miami, Florida) guide catheter inserted via the right femoral artery engaged the fistula origin in the ascending aorta. Biplane angiography demonstrated the fistulous connection (Fig. 2 and Online Video 1, and Fig. 3 and Online Video 2).
A 0.035-inch Glidewire (Terumo Medical Corporation, Somerset, New Jersey) was advanced via the guide catheter through the fistulous connection into the PA and externalized out the right femoral vein using a 25-mm loop snare (ev3 Endovascular, Plymouth, Minnesota).
Based on computed tomographic and angiographic measurements (a sizing balloon would not cross the fistula), a 12/10 mm Amplatzer Duct Occluder was selected and deployed via a TorqVue delivery sheath (St. Jude Medical, St. Paul, Minnesota) (Fig. 4). Aortography confirmed stable and ideal positioning of the device within the fistula, with dramatic reduction of flow into the PA (Fig. 5, Online Video 3).
The patient did well post-procedure without complications. At follow-up evaluation 4 months after the procedure, the patient reported improvement in his dyspnea, increased energy, and diminished peripheral edema. In addition, TTE demonstrated decreased RV size and Doppler-derived RV systolic pressure with no residual shunt.
Review of the literature failed to reveal a report of the post-transplantation complication described in our patient: formation of a fistula between the aorta and PA after heart transplantation. The approach described for percutaneous closure represents a novel and less morbid solution compared with repeat open cardiac surgery.
For accompanying videos, please see the online version of this paper.
Dr. Milano has received fees as a consultant for Thoratec Corporation and HeartWare. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received May 17, 2013.
- Revision received July 1, 2013.
- Accepted July 3, 2013.
- American College of Cardiology Foundation