Aortosubpulmonary Fistula after Konno-Rastan Aortoventriculoplasty

Figures

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  Figure 1. Preoperative TTE modified parasternal long-axis color compare image demonstrating post-Konno-Rastan CardioCel patch disintegration resulting in an anterior mass, suspicious for a pseudoaneurysm. The orange arrow identifies the site of patch disintegration. The green x marks the aortic pseudoaneurysm. The color image to the right demonstrates flow from the aorta into the pseudoaneurysm.

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  Figure 2. Preoperative TTE parasternal short-axis view demonstrating the anterior aortic pseudoaneurysm (green x) compressing the distal RVOT (orange arrow).

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  Figure 3. Preoperative TTE modified parasternal short-axis view demonstrating an anterior aortic pseudoaneurysm (green x) and a fistulous communication with the RVOT (orange arrow). Blood flows from the pseudoaneurysm into the RVOT, consistent with a left-to-right shunt.

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  Figure 4. Computed tomography scan images before and after surgical correction. (A) Aortic pseudoaneurysm. Note the connection between the ascending aorta and the pseudoaneurysm. (B) Fistulous tract between the aortic pseudoaneurysm and RVOT.

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  Figure 5. Multiplanar reconstruction CT demonstrating the pseudoaneurysm, right ventricle, and RVOT in close approximation to the mid and lower sternum. The pseudoaneurysm is marked with a yellow asterisk.

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  Figure 6. Intraoperative TEE modified bicaval view demonstrating the coronary sinus (CS) catheter (orange arrow) entering the CS. RA, Right atrium.

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  Figure 7. Intraoperative TEE ascending aortic arch short-axis view demonstrating the pulmonary endovent catheter (orange arrow) in the main pulmonary artery (MPA). Note the balloon is inflated as these catheters are placed in the same fashion as a pulmonary artery catheter. The endovent can be connected to the corresponding venting line from the CPB machine to aid in cardiac venting throughout the case. AA, Ascending aorta.

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  Figure 8. Contrast fluoroscopy with CODA endo balloon in the ascending aorta. (A) Partially inflated. The CODA balloon is inflated with contrast to allow localization of the balloon. (B) Fully inflated. Note that the inflated balloon on fluoroscopy demonstrates an indentation proximally as it extends partially into the pseudoaneurysm. This indentation signifies complete inflation of the balloon and occlusion of the ascending aorta.

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  Figure 9. Intraoperative TEE imaging with three-dimensional multiplanar reconstruction demonstrating the ascending aortic pseudoaneurysm (green x) arising from the disintegration of the aortic patch (orange arrow).

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  Figure 10. Intraoperative TEE color imaging with three-dimensional multiplanar reconstruction demonstrating the ascending aortic pseudoaneurysm (white x) arising from the disintegration of the aortic patch (orange arrow).

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  Figure 11. Surgical photograph after excision of the capsule of the aortic pseudoaneurysm and removal of the aortic patch. (A) Fistulous tract connecting the aortic pseudoaneurysm and the RVOT. (B) Bioprosthetic valve in the aortic position. (C) CODA endoballoon.

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  Figure 12. Schematic illustrations of the aortic pseudoaneurysm, fistulous tract between the pseudoaneurysm and the RVOT, and defect in the LVOT patch. The CODA balloon can be seen in the ascending aorta immediately distal to the pseudoaneurysm. The superior vena cava and inferior vena cava have been individually cannulated. (A) The anterior ascending aorta patch has disintegrated. Note the shadowed area inside the suture line above the aortic valve annulus. This disintegration formed a pseudoaneurysm, which is demonstrated as the transparent bulge anterior to the ascending aorta and RVOT. (B) With the pseudoaneurysm and external patch removed, two chambers of the heart can be seen. The superior aspect of the defect demonstrates the ascending aorta, while the inferior aspect of the defect demonstrates the RVOT. The suture line in the RVOT chamber is the ventricular septal patch, which separates the RVOT from the LVOT. A small erosion in the ventricular septal patch (LVOT) beneath the prosthetic aortic valve suture line is seen, resulting in a small ventricular septal defect. Illustrations courtesy of Dave Schumick.