Excerpt

A male over the age of 90 years presented with chest pain on exertion and recent myocardial infarction. His coronary angiogram showed no significant coronary artery disease. CT demonstrated a heavily calcified trileaflet aortic valve (Fig. 1), with a mean gradient of 44 mmHg and an aortic valve area of 0.46 cm² on transthoracic echocardiography (TTE). Our heart-team elected transfemoral transcatheter aortic valve replacement (TAVR) because of advanced age and frailty. After pre-dilation with a 26 × 30 mm balloon, a 29-mm Sapien 3 valve (Edwards Lifesciences, Irvine, CA) was deployed with a reduction of the balloon volume by 1 cc (nominal CT-based oversizing was calculated as 13%). Postprocedural TTE showed a small continuous flow jet from right coronary sinus into the right ventricle (RV, i.e., Aorto–RV fistula) at the TAVR-stent’s distal edge (Fig. 2). Initially, the patient was managed conservatively because he was asymptomatic and hemodynamically stable. After 1 month, however, he was admitted with severe heart failure (NYHA III-IV). Transesophageal echocardiography (TEE) revealed a worsening fistula (Qp/Qs = 1.7, Fig. 3). On CT, the defect measured 4.5 mm (Fig. 4). We performed transcatheter closure using a retrograde approach. An exchanged-length, angled-Glidewire (Terumo, Somerset, NJ), which was supported by a telescoped 100 cm 6-French multipurpose guide and 125 cm 5-French multipurpose diagnostic catheter, was used to cross the defect. With the Glidewire in place we then exchanged for a 6-French shuttle sheath (Cook Medical, Bloomington, IN) and advanced it across the defect without a wire-rail (Fig. 5). A 6-mm Amplatzer Duct Occluder II (ADO-II, St. Jude Medical, Fridley, MN) was successfully deployed (Figs. 6, 7). After deployment of the ADO-II, only mild shunting was observed on TEE (Fig. 8). The patient’s symptoms improved dramatically, and he was discharged to home the next day.

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