Iatrogenic Aorto–Right Ventricular Fistula: A Rare Complication of Transcatheter Valve Implantation

Figures

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  Figure 1. Contrast-enhanced aortogram (left anterior oblique, 35°; cranial, 5°) was low quality but demonstrated normal flow across the transcatheter valve (TAV; arrow) and no evidence of PVL or communication between the aorta and the adjacent chambers. AO, Aorta; TAV, transcatheter AV.

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  Figure 2. Two-dimensional TTE-guided continuous-wave spectral Doppler display from the parasternal short-axis view demonstrates flow across the shunt that was parallel to the ultrasound beam and ideal for estimation of the maximum velocity. There is continuous flow above the baseline suggestive of flow from the aorta to the RV with a peak velocity measured at 2.9 m/sec.

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  Figure 3. Two-dimensional TTE parasternal long-axis view without (left) and with (right) color flow Doppler demonstrates the ARV fistula (arrow) with flow from the AO to the RV. The fistula measures 0.45 cm from this view. AO, Aorta; LA, left atrium.

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  Figure 4. Two-dimensional TTE parasternal short-axis view with color flow Doppler demonstrates the ARV fistula (arrow) with flow from the AO to the RV. AO, Aorta; LA, left atrium.

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  Figure 5. Two-dimensional TTE apical 5-chamber view with color flow Doppler demonstrates the ARV fistula (arrow), with flow from the AO to the RV. The fistula measured 0.87 cm in this view. AO, Aorta.

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  Figure 6. MDCT sagittal view demonstrates the TAVI and the location of the ARV fistula (arrow). LA, Left atrium; LV, left ventricle; PA, pulmonary artery; RVOT, RV outflow tract.

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  Figure 7. MDCT image, volume-rendered whole-heart reconstruction image post-TAVI demonstrates the location of the fistula (arrow). The RV and RA have been faded out (dark gray) to better visualize the fistula. AO, Aorta; LA, left atrium; RA, right atrium.

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  Figure 8. Two-dimensional TEE, zoomed midesophageal long-axis (142°) view without (left) and with (right) color flow Doppler demonstrates a communication between the aorta and the RV with left-to-right shunt (arrow). AO, Aorta; LA, left atrium.

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  Figure 9. Three-dimensional TEE, midesophageal volume-rendered image with color flow Doppler demonstrates the ARV fistula (arrow). AO, Aorta; LA, left atrium.

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  Figure 10. Two-dimensional TEE, midesophageal x-plane views (35° and 121°) demonstrate simultaneous orthogonal images of the origin of the ARV fistula (arrows). AO, Aorta; LA, left atrium; RA, right atrium.

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  Figure 11. MDCT image, oblique axial display at baseline pre-TAVI (A) and post-TAVI (B) demonstrates focal heavy calcification within all cusps, but greatest at the right cusp (arrow), which is also the location of the subsequent ARV fistula post-TAVI (arrow). AO, Aorta; LA, left atrium

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  Figure 12. MDCT image, short-axis view of the aortic annulus at baseline pre-TAVI (A) and post-TAVI (B) demonstrates heavy calcification within all cusps including the right cusp (arrow) and its relationship to the site of subsequent ARV fistula (∗∗). LA, Left atrium; RA, right atrium.