Percutaneous closure of an iatrogenic aorto-right atrial fistula of the sinus of Valsalva through total arm approach: a case report

Figure 1. Transoesophageal echocardiography showing a 6 mm colour jet (a) originating from the non-coronary cusp of the aortic root (b) towards the right atrium (c). Left atrium (d). Right ventricular outflow tract (e).

Figure 2. Aortography. Ascending aorta (a). Mitral valve prosthesis (b). Torrential flow across the non-coronary cusp (c). Right atrium (d). Left main coronary artery (e). 5 Fr diagnostic catheter (f).

Figure 3. Probing of the fistula and creation of an arteriovenous loop. (A) Retrograde crossing of the aorto-atrial fistula using a glidewire (a) and a 5 Fr MP-II guiding catheter (b) under fluoroscopic and transoesophageal echocardiography (c) guidance. (B) Snaring (d) of the retrograde wire (a) via right basilic vein into a venous 6 Fr sheath (e). (C) Mother–child technique: the retrograde MP-II-guide catheter (b) is negotiated into the venous 6 Fr sheath (e).

Figure 4. Deployment of the Amplatzer Vascular Plug. (A) Partial release of the left lobe (a) of the Amplatzer Vascular Plug from the 6 Fr sheath (b), which is advanced into the right subclavian artery. (B) After the sheath (b) and the Amplatzer Vascular Plug are withdrawn back to the aortic root, the left lobe (a) of the Amplatzer Vascular Plug is completely released at the entry site of the fistula in the non-coronary aortic cusp, while the right lobe (c) of the Amplatzer Vascular Plug is released at the right atrial exit site. (C) Final angiography demonstrating complete sealing of the fistula in the non-coronary cusp (d) by the Amplatzer Vascular Plug (e) with no increase in mild aortic regurgitation.