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Percutaneous closure of a para-prosthetic aorto-right ventricular fistula
International Journal of Cardiology 118 (2007) e31 – e34 www.elsevier.com/locate/ijcard
Letter to the Editor
Percutaneous closure of a para-prosthetic aorto-right ventricular fistula Marvin H. Eng a , Joel A. Garcia a , Adam Hansgen a , Kak-Chen Chan b , John D. Carroll a,⁎ a
University of Colorado Hospital and Health Sciences Center (UCHSC), Division of Cardiology, Denver, CO, United States b The Children's Hospital, Division of Cardiology, Denver, CO, United States Received 20 November 2006; accepted 31 December 2006 Available online 26 March 2007
Abstract A 60-year-old woman with increasing dyspnea was found to have a para-prosthetic aorto-right ventricular fistula during post-operative evaluation. Due to her multiple sternotomies, she was considered to be high risk for open surgical repair and referred for percutaneous intervention. A 6/4 mm Amplatzer occluder device (AGA Medical, Golden Valley, MN) was successfully delivered across the fistula with excellent immediate angiographic results. © 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Sinus of Valsalva fistula; Amplatzer PDA device; Percutaneous intervention
1. Introduction
2. Case
Aorto-cardiac fistulas are a rare complication of trauma [1], endocarditis [2], rupture of sinus of Valsalva aneurysms [3–5] (SOVa) and cardiac valve replacement [6–8]. The mortality of aorto-cardiac fistulas has been reported to be as high as fifty-five percent [2]. Surgical repair of aorto-cardiac fistulas has been noted to be uncomplicated [4] but the looming morbidity of repeat sternotomy, aortic valve replacement (AVR) and possible fistula recurrence makes percutaneous repair an appealing option. The evolution of Amplatzer occluder devices for treatment of congenital intra-cardiac defects presents an effective alternative to surgery [9]. We describe the successful utilization of an Amplatz patent ductus arteriosus (PDA) closure device (AGA Medical, Golden Valley, MN) for percutaneous closure of an aorto-right ventricular (RV) fistula.
A 60-year-old woman was referred for increasing dyspnea. She had previously undergone AVR in 2001 for severe aortic stenosis and was later found to have severe mitral regurgitation in 2004. She underwent mitral valve replacement with a #25 Carbomedics mechanical valve; however, severe aortic root scarring and contraction necessitated repeat AVR with a #19 Carbomedics mechanical valve. Her post-operative course was complicated by complete heart block and severe bleeding prompting reexploration and dual chamber pacemaker insertion. During a routine follow up appointment, an echocardiogram revealed a sinus of Valsalva aneurysm with aorto-RV shunting and she was referred for possible percutaneous repair in light of her multiple sternotomies. Subsequent evaluation via right heart catheterization revealed a left to right shunt (Qp/Qs 1.5:1), pulmonary hypertension (PAP = 37/12 mm Hg, mean = 23) with elevated left and right ventricular filling pressures (PCWP = 15 mm Hg, RA = 15 mm Hg). An aortogram demonstrated an irregularly shaped fistula 3–6 mm wide within the mid-portion of the septum with brisk flow from the aortic sinus to the RV (Fig. 1A). We proceeded with elective fistula closure by advancing a JR-4 (Cordis
⁎ Corresponding author. University Hospital, 4200 E. Ninth Avenue, Rm B-130, CO 80262, United States. Tel.: +1 303 372 6555; fax: +1 303 372 6644. E-mail address: [email protected] (J.D. Carroll). 0167-5273/$ - see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2006.12.004
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Fig. 1. (A) Anterior–posterior (AP) view of an aortic angiogram with a pigtail catheter located in the aortic root showing brisk extravasation of contrast into the RV (arrows). (B) The JR-4 catheter is advanced across the fistula into the RV. (C) A stiff angled Glidewire is positioned in the RV through the JR-4 catheter and captured by the Amplatz Gooseneck snare (arrow) to create an arterial–venous loop. (D) An Amplatz PDA closure device (double arrow) is loaded onto a delivery cable and positioned across the fistula using the arterial–venous loop under intra-cardiac echocardiographic (ICE) guidance (single arrow).
Corporation, Miami, FL) diagnostic catheter into the ascending aorta across the fistula with a guidewire and advancing the catheter into the RV across the fistula (Fig. 1B). A stiff-angled Glidewire (Terumo Medical Corporation, Somerset, NJ) was positioned into the RV and subsequently advanced into the right atrium (RA) and the superior vena cava (SVC). The JR-4 catheter was further advanced into the SVC and the Glidewire was captured and externalized out the right femoral vein via an Amplatzer Gooseneck snare (Microvena Corp., White Bear Lake, MN) (Fig. 1C). An Amplatzer delivery system 7F was then exchanged for the venous sheath over the Glidewire and advanced to the fistula from the right femoral vein. By slowly retracting the JR-4 catheter in parallel with advancing the delivery catheter, the arterial-venous circuit was used to advance the delivery system across the fistula (Fig. 1D). A 6/4 mm Amplatz PDA closure cable inserted into the delivery catheter and was advanced across the fistula, subsequently the distal aspect of the PDA device was advanced outside of the delivery catheter, pulled back against the aortic origin of the fistula and then the rest of the PDA device was deployed in the fistula (Fig. 2A). Intra-cardiac echocardiography (ICE) (Siemens Medical, Mountain View, CA), trans-esophageal
echocardiography (TEE), and fluoroscopy were used to verify secure positioning of the closure device (Fig. 2B). Repeat aortogram and Doppler echocardiography showed minimal flow across the device demonstrating excellent immediate angiographic results (Fig. 2C), the device was released, and the delivery cable was withdrawn (Fig. 2D). The patient was admitted to the medical intensive care unit for further observation. 3. Discussion Aortic–cardiac fistulas are rare, particularly as a complication of valve replacement [6–8]. Several mechanisms of injury have been proposed: inadvertent injury to the membranous septum during dissection below the noncoronary cusp; aggressive debridement of calcium from the annulus; improper retraction injuring valvular structures; and suturing through the membranous portion of the ventricular septum when implanting a prosthetic valve [8]. The surgical experience in closing aorto-cardiac shunts has mainly been in SOVa rupture [3–5]. SOVas occur in 0.14–3.5% of all congenital anomalies [10] and ruptures in 40–76% of these patients [11]. Corrective surgery for aortic
M.H. Eng et al. / International Journal of Cardiology 118 (2007) e31–e34
e33
Fig. 2. (A) In preparation for device delivery, the JR-4 catheter is disengaged and the device is positioned across the fistula (arrow). (B) ICE (single arrow) guided positioning of the Amplatz PDA closure device (double arrow) across the fistula. (C) Assessment of the aortic root after closure with a repeat aortogram demonstrating minor residual shunting (arrow). (D) Release of a stable Amplatz PDA closure device (arrow) from the delivery cable (double arrow).
sinus rupture has been demonstrated to be safe with a mortality of 2% but aortic regurgitation can develop afterwards or the lesion may recur [4]. The right ventricle is the most common location for SOVa rupture [3] and has been observed to have a 24% re-operation rate in a case series of 21 patients with aorto-RV fistulas [5]. Postoperative prognosis is good with a reported 88% 14-year survival rate among a cohort of 55 patients with three repeat surgeries for valve dehiscence [4]. Percutaneous closure of aortic–cardiac fistulas has been successful in both paravalvular leaks and SOVa rupture. Reports as early as 1992 describe a Rashkind umbrella used to close paravalvular leaks in multiple patients and notably patients with aortic–RV fistulas [12,13]. Transcatheter closure of a SOVa rupture was first published in 1994 [14] and in a subsequent series of eight patients; Rashkind umbrellas, patent foramen ovale (PFO) and PDA closure devices were efficaciously utilized to seal aorto-cardiac fistulas [15]. We followed the strategy of creating a continuous arterial–venous guidewire circuit to facilitate delivery catheter positioning and deployment of an occlusion device from the venous side to ensure stability during the procedure and spare the femoral artery from a large sheath [11]. This report documents another application of Amplatz
closure devices in the expanding breadth of percutaneous interventions. References [1] Samuels LE, Kaufman MS, Rodriguez-Vega J, Morris RJ, Brockman SK. Diagnosis and management of traumatic aorto-right ventricular fistulas. Ann Thorac Surg Jan 1998;65(1):288–92 [Review]. [2] Anguera I, Quaglio G, Miro JM, et al. Aortocardiac fistulas complicating infective endocarditis. Am J Cardiol 2001;87(5):652–4. [3] Lin CY, Hong GJ, Lee KC, Tsai YT, Tsai CS. Ruptured congenital sinus of Valsalva aneurysms. J Card Surg 2004;19:99–102. [4] Vural KM, Sener E, Tasdemir O, Bayazit K. Approach to sinus of Valsalva aneurysms: a review of 53 cases. Eur J Cardio Thorac Surg 2001;20:71–6. [5] van Son J, Danielson GK, Schaff, et al. Long-term outcome of surgical repair of ruptured sinus of Valsalva aneurysm. Circulation 1994;90(5): 20–9. [6] Alam M. Transesophageal color flow Doppler features of aorta to right ventricle fistula. Chest 1993;103(6):1907–8. [7] Roy D, Saba S, Grinberg I, et al. Aorto-right ventricular fistula: a late complication of aortic valve replacement. Tex Heart Inst J 1999;26 (2):140–2. [8] Lorenz J, Reddy CVR, Khan R, Hoover E, Hsu HK, El-Sherif N. Aorto-right ventricular shunt following aortic valve replacement. Chest 1983;83(6):922–5. [9] Holzer R, Hijazi ZM. Interventional approach to congenital heart disease. Curr Opin Cardiol 2004;19:84–90.
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M.H. Eng et al. / International Journal of Cardiology 118 (2007) e31–e34
[10] Fedson S, Jolly N, Lang RM, Hijazi ZM. Percutaneous closure of a ruptured sinus of Valsalva aneurysm using the Amplatzer Duct Occluder. Catheter Cardiovasc Interv 2003;58(3):412. [11] Hijazi ZM. Ruptured sinus of valsalva aneurysm: management options. Catheter Cardiovasc Interv 2003;58(1):135–6. [12] Hourihan M, Stanton BP, Mandell VS, et al. Transcatheter umbrella closure of valvular and paravalvular leaks. J Am Coll Cardiol 1992;20 (6):1371–7. [13] Dussaillant GR, Romero L, Ramirez A, Sepulveda L. Successful percutaneous closure of paraprosthetic aorto-right ventricular leak
using the Amplatzer Duct Occluder. Catheter Cardiovasc Interv 2006;67:976–80. [14] Cullen S, Somerville J, Redington A. Transcatheter closure of a ruptured aneurysm of the sinus of Valsalva. Br Heart J 1994;71:479–80. [15] Arora R, Trehan V, Rangasetty UM, Mukhopadhyay S, Thakur AK, Kalra GS. Transcatheter closure of ruptured sinus of valsalva aneurysm. J Interv Cardiol 2004;17(1):53–8.
Letter to the Editor
Percutaneous closure of a para-prosthetic aorto-right ventricular fistula Marvin H. Eng a , Joel A. Garcia a , Adam Hansgen a , Kak-Chen Chan b , John D. Carroll a,⁎ a
University of Colorado Hospital and Health Sciences Center (UCHSC), Division of Cardiology, Denver, CO, United States b The Children's Hospital, Division of Cardiology, Denver, CO, United States Received 20 November 2006; accepted 31 December 2006 Available online 26 March 2007
Abstract A 60-year-old woman with increasing dyspnea was found to have a para-prosthetic aorto-right ventricular fistula during post-operative evaluation. Due to her multiple sternotomies, she was considered to be high risk for open surgical repair and referred for percutaneous intervention. A 6/4 mm Amplatzer occluder device (AGA Medical, Golden Valley, MN) was successfully delivered across the fistula with excellent immediate angiographic results. © 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Sinus of Valsalva fistula; Amplatzer PDA device; Percutaneous intervention
1. Introduction
2. Case
Aorto-cardiac fistulas are a rare complication of trauma [1], endocarditis [2], rupture of sinus of Valsalva aneurysms [3–5] (SOVa) and cardiac valve replacement [6–8]. The mortality of aorto-cardiac fistulas has been reported to be as high as fifty-five percent [2]. Surgical repair of aorto-cardiac fistulas has been noted to be uncomplicated [4] but the looming morbidity of repeat sternotomy, aortic valve replacement (AVR) and possible fistula recurrence makes percutaneous repair an appealing option. The evolution of Amplatzer occluder devices for treatment of congenital intra-cardiac defects presents an effective alternative to surgery [9]. We describe the successful utilization of an Amplatz patent ductus arteriosus (PDA) closure device (AGA Medical, Golden Valley, MN) for percutaneous closure of an aorto-right ventricular (RV) fistula.
A 60-year-old woman was referred for increasing dyspnea. She had previously undergone AVR in 2001 for severe aortic stenosis and was later found to have severe mitral regurgitation in 2004. She underwent mitral valve replacement with a #25 Carbomedics mechanical valve; however, severe aortic root scarring and contraction necessitated repeat AVR with a #19 Carbomedics mechanical valve. Her post-operative course was complicated by complete heart block and severe bleeding prompting reexploration and dual chamber pacemaker insertion. During a routine follow up appointment, an echocardiogram revealed a sinus of Valsalva aneurysm with aorto-RV shunting and she was referred for possible percutaneous repair in light of her multiple sternotomies. Subsequent evaluation via right heart catheterization revealed a left to right shunt (Qp/Qs 1.5:1), pulmonary hypertension (PAP = 37/12 mm Hg, mean = 23) with elevated left and right ventricular filling pressures (PCWP = 15 mm Hg, RA = 15 mm Hg). An aortogram demonstrated an irregularly shaped fistula 3–6 mm wide within the mid-portion of the septum with brisk flow from the aortic sinus to the RV (Fig. 1A). We proceeded with elective fistula closure by advancing a JR-4 (Cordis
⁎ Corresponding author. University Hospital, 4200 E. Ninth Avenue, Rm B-130, CO 80262, United States. Tel.: +1 303 372 6555; fax: +1 303 372 6644. E-mail address: [email protected] (J.D. Carroll). 0167-5273/$ - see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2006.12.004
e32
M.H. Eng et al. / International Journal of Cardiology 118 (2007) e31–e34
Fig. 1. (A) Anterior–posterior (AP) view of an aortic angiogram with a pigtail catheter located in the aortic root showing brisk extravasation of contrast into the RV (arrows). (B) The JR-4 catheter is advanced across the fistula into the RV. (C) A stiff angled Glidewire is positioned in the RV through the JR-4 catheter and captured by the Amplatz Gooseneck snare (arrow) to create an arterial–venous loop. (D) An Amplatz PDA closure device (double arrow) is loaded onto a delivery cable and positioned across the fistula using the arterial–venous loop under intra-cardiac echocardiographic (ICE) guidance (single arrow).
Corporation, Miami, FL) diagnostic catheter into the ascending aorta across the fistula with a guidewire and advancing the catheter into the RV across the fistula (Fig. 1B). A stiff-angled Glidewire (Terumo Medical Corporation, Somerset, NJ) was positioned into the RV and subsequently advanced into the right atrium (RA) and the superior vena cava (SVC). The JR-4 catheter was further advanced into the SVC and the Glidewire was captured and externalized out the right femoral vein via an Amplatzer Gooseneck snare (Microvena Corp., White Bear Lake, MN) (Fig. 1C). An Amplatzer delivery system 7F was then exchanged for the venous sheath over the Glidewire and advanced to the fistula from the right femoral vein. By slowly retracting the JR-4 catheter in parallel with advancing the delivery catheter, the arterial-venous circuit was used to advance the delivery system across the fistula (Fig. 1D). A 6/4 mm Amplatz PDA closure cable inserted into the delivery catheter and was advanced across the fistula, subsequently the distal aspect of the PDA device was advanced outside of the delivery catheter, pulled back against the aortic origin of the fistula and then the rest of the PDA device was deployed in the fistula (Fig. 2A). Intra-cardiac echocardiography (ICE) (Siemens Medical, Mountain View, CA), trans-esophageal
echocardiography (TEE), and fluoroscopy were used to verify secure positioning of the closure device (Fig. 2B). Repeat aortogram and Doppler echocardiography showed minimal flow across the device demonstrating excellent immediate angiographic results (Fig. 2C), the device was released, and the delivery cable was withdrawn (Fig. 2D). The patient was admitted to the medical intensive care unit for further observation. 3. Discussion Aortic–cardiac fistulas are rare, particularly as a complication of valve replacement [6–8]. Several mechanisms of injury have been proposed: inadvertent injury to the membranous septum during dissection below the noncoronary cusp; aggressive debridement of calcium from the annulus; improper retraction injuring valvular structures; and suturing through the membranous portion of the ventricular septum when implanting a prosthetic valve [8]. The surgical experience in closing aorto-cardiac shunts has mainly been in SOVa rupture [3–5]. SOVas occur in 0.14–3.5% of all congenital anomalies [10] and ruptures in 40–76% of these patients [11]. Corrective surgery for aortic
M.H. Eng et al. / International Journal of Cardiology 118 (2007) e31–e34
e33
Fig. 2. (A) In preparation for device delivery, the JR-4 catheter is disengaged and the device is positioned across the fistula (arrow). (B) ICE (single arrow) guided positioning of the Amplatz PDA closure device (double arrow) across the fistula. (C) Assessment of the aortic root after closure with a repeat aortogram demonstrating minor residual shunting (arrow). (D) Release of a stable Amplatz PDA closure device (arrow) from the delivery cable (double arrow).
sinus rupture has been demonstrated to be safe with a mortality of 2% but aortic regurgitation can develop afterwards or the lesion may recur [4]. The right ventricle is the most common location for SOVa rupture [3] and has been observed to have a 24% re-operation rate in a case series of 21 patients with aorto-RV fistulas [5]. Postoperative prognosis is good with a reported 88% 14-year survival rate among a cohort of 55 patients with three repeat surgeries for valve dehiscence [4]. Percutaneous closure of aortic–cardiac fistulas has been successful in both paravalvular leaks and SOVa rupture. Reports as early as 1992 describe a Rashkind umbrella used to close paravalvular leaks in multiple patients and notably patients with aortic–RV fistulas [12,13]. Transcatheter closure of a SOVa rupture was first published in 1994 [14] and in a subsequent series of eight patients; Rashkind umbrellas, patent foramen ovale (PFO) and PDA closure devices were efficaciously utilized to seal aorto-cardiac fistulas [15]. We followed the strategy of creating a continuous arterial–venous guidewire circuit to facilitate delivery catheter positioning and deployment of an occlusion device from the venous side to ensure stability during the procedure and spare the femoral artery from a large sheath [11]. This report documents another application of Amplatz
closure devices in the expanding breadth of percutaneous interventions. References [1] Samuels LE, Kaufman MS, Rodriguez-Vega J, Morris RJ, Brockman SK. Diagnosis and management of traumatic aorto-right ventricular fistulas. Ann Thorac Surg Jan 1998;65(1):288–92 [Review]. [2] Anguera I, Quaglio G, Miro JM, et al. Aortocardiac fistulas complicating infective endocarditis. Am J Cardiol 2001;87(5):652–4. [3] Lin CY, Hong GJ, Lee KC, Tsai YT, Tsai CS. Ruptured congenital sinus of Valsalva aneurysms. J Card Surg 2004;19:99–102. [4] Vural KM, Sener E, Tasdemir O, Bayazit K. Approach to sinus of Valsalva aneurysms: a review of 53 cases. Eur J Cardio Thorac Surg 2001;20:71–6. [5] van Son J, Danielson GK, Schaff, et al. Long-term outcome of surgical repair of ruptured sinus of Valsalva aneurysm. Circulation 1994;90(5): 20–9. [6] Alam M. Transesophageal color flow Doppler features of aorta to right ventricle fistula. Chest 1993;103(6):1907–8. [7] Roy D, Saba S, Grinberg I, et al. Aorto-right ventricular fistula: a late complication of aortic valve replacement. Tex Heart Inst J 1999;26 (2):140–2. [8] Lorenz J, Reddy CVR, Khan R, Hoover E, Hsu HK, El-Sherif N. Aorto-right ventricular shunt following aortic valve replacement. Chest 1983;83(6):922–5. [9] Holzer R, Hijazi ZM. Interventional approach to congenital heart disease. Curr Opin Cardiol 2004;19:84–90.
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M.H. Eng et al. / International Journal of Cardiology 118 (2007) e31–e34
[10] Fedson S, Jolly N, Lang RM, Hijazi ZM. Percutaneous closure of a ruptured sinus of Valsalva aneurysm using the Amplatzer Duct Occluder. Catheter Cardiovasc Interv 2003;58(3):412. [11] Hijazi ZM. Ruptured sinus of valsalva aneurysm: management options. Catheter Cardiovasc Interv 2003;58(1):135–6. [12] Hourihan M, Stanton BP, Mandell VS, et al. Transcatheter umbrella closure of valvular and paravalvular leaks. J Am Coll Cardiol 1992;20 (6):1371–7. [13] Dussaillant GR, Romero L, Ramirez A, Sepulveda L. Successful percutaneous closure of paraprosthetic aorto-right ventricular leak
using the Amplatzer Duct Occluder. Catheter Cardiovasc Interv 2006;67:976–80. [14] Cullen S, Somerville J, Redington A. Transcatheter closure of a ruptured aneurysm of the sinus of Valsalva. Br Heart J 1994;71:479–80. [15] Arora R, Trehan V, Rangasetty UM, Mukhopadhyay S, Thakur AK, Kalra GS. Transcatheter closure of ruptured sinus of valsalva aneurysm. J Interv Cardiol 2004;17(1):53–8.