Percutaneous Treatment of an Aorto-Right Ventricular Fistula Following Balloon-Expandable Transcatheter Aortic Valve Replacement

Figures

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  Figure 1. Preprocedural Cardiac Computed Tomography Imaging (A) 3-dimensional reconstructions and (B) maximum intensity projection imaging demonstrated a heavily calcified trileaflet aortic valve.

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  Figure 2. Transcatheter Aortic Valve Replacement Procedural Imaging (A) Cineangiography revealed a heavily calcified aortic valve. (B) Final valve implantation depth.

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  Figure 3. Preprocedural Transthoracic Echocardiographic Imaging (A, B) Parasternal long-axis imaging demonstrated an aorto-right ventricular fistula. (C, D) These findings were confirmed on short-axis imaging.

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  Figure 4. Preprocedural Cardiac Computed Tomography Imaging (A to C) The defect was assessed in multiplanar and (D) 3-dimensional reconstructions.

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  Figure 5. Periprocedural Transesophageal Echocardiography Transgastric right ventricular inflow views were helpful in (A) identifying the defect, (B) confirming crossing of the guiding catheter, (C) positioning of the closure device, and (D) assessing for defect closure.

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  Figure 6. Periprocedural Fluoroscopy Cineangiography was performed in (A) right anterior oblique, (B) left anterior oblique cranial, and (C) left anterior oblique projections, identifying an optimal crossing angle. (D, E) The defect was crossed, and (F, G) the guiding catheter was advanced into the right ventricle using a mother-child technique. (H) A vascular plug would not advance through the guide because of (I) significant iliofemoral tortuosity and (J-L) upgrading of the equipment to a 7-F system. (M, N) The initial deployment was too distal, so (O) the device was partially recaptured and (P to R) positioned more proximally. (S, T) Final device positioning was satisfactory.

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  Figure 7. Postprocedural Cardiac Computed Tomography Imaging (A to C) There was only a minimal residual defect. (D) Three-dimensional reconstructions demonstrated satisfactory device positioning.