Percutaneous Closure of an Iatrogenic Aorta to Right Ventricle Fistula Acquired Following Intracardiac Repair - PDF Document

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  1. Acta Cardiol Sin 2016;32:371?374 doi: 10.6515/ACS20150701A Case Report Percutaneous Closure of an Iatrogenic Aorta to Right Ventricle Fistula Acquired Following Intracardiac Repair Durgaprasad Rajasekhar, Velam Vanajakshamma and Kummaraganti Paramathma Ranganayakulu Iatrogenic aortocardiac fistulae have been described rarely following intracardiac repair. This 28 year-old-male presented to our facility with dyspnea going on 20 days after closure of ventricular septal defect (VSD) and resection of subaortic membrane. A communication was noticed between the aorta and the right ventricle (RV) upon transthoracic echocardiography. Cardiac catheterisation revealed a significant shunt and an aortogram revealed a 6 mm communication between aorta and right ventricle. Percutaneous closure of this defect was attempted under local anaesthesia through right femoral access. An alpha arteriovenous loop was formed despite repeatedattempts,hencearetrogradeapproachfordevicedeliverywasconsidered.An8mmAmplatzermuscular VSD occluder device was deployed across the defect achieving a complete closure through an 8F delivery sheath. To the best of our knowledge this is the first report of an iatrogenic aorta to RV fistula occurring in a patient following an intracardiac repair which has been successfully treated percutaneously. Key Words: Aortocardiac fistula ? Aorto-RV fistula ? Iatrogenic ? Percutaneous intervention ? Transcatheter closure INTRODUCTION redo surgery. We report this unique case of an acquired aorta to right ventricle (RV) fistula following an intra- cardiac repair for VSD along with resection of subaortic membrane where successful closure of this iatrogenic fistula could be achieved percutaneously. Fistulae between the aorta and cardiac cavities are rare entities which are usually seen following rupture of sinus of Valsalva aneuryms, as a complication of infec- tive endocarditis and trauma. These have also been de- scribed following surgeries on aortic valves1,2and very rarely following repair of ventricular septal defects (VSD).3,4Though a redo cardiac surgery is the gold stan- dard in treating an acquired iatrogenic aortocardiac fistulae, percutaneous interventions are emerging as a safe and attractive alternative when the patient refuses CASE REPORT A twenty-eight year old farmer was diagnosed with 5 mm subpulmonic VSD with subaortic membrane for which surgical closure of VSD along with resection of subaortic membrane was done. He presented to us 20 days after surgery with dyspnea and palpitations of New York heart association class III. On examination he was afebrile, tachypneic and a continuous murmur of grade 4/6 was heard along the left parasternal region with maximum intensity over the 3rdand 4thleft intercostal spaces. Echocardiogram revealed an intact VSD patch with Received: April 14, 2015 Department of Cardiology,SVIMS,Tirupati, Andhra Pradesh, India. Address correspondence and reprint requests to: Dr. D. Rajasekhar, Department of Cardiology, Sri Venkateswara Institute of Medical Sciences & University, Tirupati – 517507, Andhra Pradesh, India. Tel: +91-9849221650; Fax: +91-877-2288133; E-mail: cardiologysvims@ gmail.com Accepted: July 1, 2015 371 Acta Cardiol Sin 2016;32:371?374

  2. Durgaprasad Rajasekhar et al. pulmonary artery, which was later snared through the right femoral vein with a 10 mm angled wire loop re- triever (Cook Medical, Bjaeverskov, Denmark), forming a arteriovenous loop. An alpha loop was formed in the right ventricle despite repeated attempts, hence a retro- grade approach was considered for device delivery to avoid entanglement of the tricuspid valve apparatus (Figure 2A). Over the wire, 8F Check-Flo Performer In- troducer (Cook Medical, Bjaeverskov, Denmark) was in- troduced through right femoral arterial access and ad- vanced. The wire was withdrawn once the sheath had crossed the defect. An 8 mm Amplatzer muscular VSD occluder device (AGA Medical, Plymouth, Minnesota, USA) with the delivery system was then advanced th- rough the sheath. The disc on the RV side was initially released, and after confirming its position on TTE and fluoroscopy, the aortic end was delivered by further withdrawing the sheath (Figure 2B). The device was held in position across the defect for several minutes, and the electrocardiographic monitor was observed for con- duction disturbances and ST-T changes. Prior to final re- no left ventricular outflow tract gradient. A communica- tion was noticed between the right aortic sinus and RV (Figure 1A, B, C). Conventional aortogram with a 6F pig- tail catheter was performed which revealed a 6 mm communication between the right aortic sinus and the RV (Figure 1D) with significant shunt (Qp/Qs = 1.8:1) and with a systolic pulmonary artery pressure of 34 mm Hg. Therefore, device closure was attempted under local anaesthesia after obtaining appropriate informed con- sent. Right femoral arterial and venous accesses were achieved with 6F and 7F introducers. The entire proce- dure was done under fluoroscopy and transthoracic echocardiography (TTE) guidance. A 6F Judkins right catheter (Cordis Corporation, Miami Lakes, Florida, USA) was passed from the aortic side across the defect into RV using a hydrophilic guidewire 0.035 inch ? 150 cm (Terumo Corporation, Tokyo, Japan). This was then ex- changed over with a 0.035 inch ? 260 cm hydrophilic ex- change length guide wire (Terumo Corporation, Tokyo, Japan). The floppy end of the wire was delivered across the defect into the right ventricle and advanced into the B A C D Iatrogenic communication between aorta (right coronary sinus) and right ventricle on 2D echocardiography and on aortogram. (A) Fis- Figure 1. tula (arrow) between aorta and right ventricle seen in apical 5 chamber view. (B) Fistula (arrow) between aorta (right coronary sinus) and right ven- tricle seen in parasternal short axis view. (C) Fistula (arrow) between aorta and right ventricle seen in parasternal long axis view. (D) Aortgram in AP view demonstrating a 6mm communication between aorta and right ventricle (arrow). 372 Acta Cardiol Sin 2016;32:371?374

  3. Percutaneous Closure of Iatrogenic Aorto RV Fistula lease of the device, its position was confirmed by a hand injection accomplished through the delivery sheath and TTE. Repeat aortogram after the deployment of the de- vice across the fistula revealed no residual leak across the device, no aortic regurgitation and good perfusion of the right coronary artery (Figure 2C). Repeat echo done post procedure and after 2 days revealed a satis- factory position of the occluder device with no residual leak across the defect (Figure 2D). Subsequently, the pa- tient was discharged on dual antiplatelets. Three months later, routine follow-up indicated that the patient had no limitation of his routine activities, and repeat TTE re- vealed no residual leak across the defect. following surgery on aortic valve, but very rarely follow- ing repair of a high VSD. Inadvertent injury to the aortic sinus during resection of the subaortic membrane or re- pair of VSD or psuedoaneurysmal rupture could have been the likely cause for such a communication in our patient. The high pressure gradient between the aorta and RV during the entire cardiac cycle causes an obvious continuous left to right shunt. This shunt, when large enough, can result in RV overload and congestive heart failure. The natural history of patients with iatrogenic aorta to RV fistula has not been well-studied, but Samuels et al.5studied the pathophysiology and natural history in patients with traumatic aorto-RV fistulae and reported that early diagnosis and prompt treatment are necessary to prevent development of congestive heart failure. Although surgery is the primary treatment option, DISCUSSION Iatrogenic aorto-RV fistulae have been described B A C D (A) Alpha arteriovenous loop (arrow) in view of which a retrograde approach was considered for device delivery. (B) Depicting 8 mm Figure 2. Amplatzer muscular ventricular septal defect (VSD) occluder device (arrow) positioned retrogradely across the aorto-right ventricular fistula seen in AP view. (C) Post procedure aortogram in AP view showing the Amplatzer muscular VSD occluder device (arrow) in position across the aorto-right ventricular fistula with no residual shunt. (D) Post procedure transthoracic echocardiography showing the Amplatzer muscular VSD occluder device in position across the aorto-right ventricular fistula with no residual shunt. 373 Acta Cardiol Sin 2016;32:371?374

  4. Durgaprasad Rajasekhar et al. REFERENCES percutaneous treatments have emerged as an attractive alternative in these patients. Among the Amplatzer occluder devices, case reports of the Amplatzer duct occluder being used in aorto-RV fistulae acquired fol- lowing aortic valve replacement exist.1,2An Amplatzer muscular VSD occlude device was used because this pa- tient had a large defect (6 mm) with a thick waist which was retrogradely closed. To the best of our knowledge this is the first report of iatrogenic aorta to RV fistula occurring in a patient following resection of subaortic membrane and repair of VSD which has been successfully treated percutaneously with an Amplatzer muscular VSD occluder device. In conclusion, percutaneous closure of iatrogenic aorta-RV fistulae is a safe, cost effective treatment alter- native to redo surgery, though a successful outcome is dependent on the anatomy of the defect. 1. 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. 2. Eng MH, Garcia JA, Hansgen A, et al. Percutaneous closure of a para-prosthetic aorto-right ventricular fistula. Int J Cardiol 2007; 118:e31-4. 3. Matsushita T, Masuda S, Inoue T, Okawa Y. Perforation of sinus Valsalva 10 years after repair of ventricular septal defect. Asian CardiovascThorac Ann 2012;20:353. 4. Gao L, Wu Q, Xu X, et al. Minimally invasive transthoracic device closureofanacquiredsinus ofValsalva-rightventriclefistulaina pediatric patient. Iran J Pediatr 2014;24:327-30. 5. Samuels LE, Kaufman MS, Rodriguez-Vega J, et al. Diagnosis and management of traumatic aorto-right ventricular fistulas. Ann Thorac Surg 1998;65:288-92. CONFLICT OF INTEREST None. 374 Acta Cardiol Sin 2016;32:371?374