Portal de Periódicos da CAPES

Aortopulmonary Fistula After Transcatheter Pulmonary Valve Replacement

2013; Lippincott Williams & Wilkins; Volume: 6; Issue: 6 Linguagem: Inglês

10.1161/circinterventions.113.000654

1941-7632

Damien Kenny, Noa Holoshitz, David A. Turner, Ziyad M. Hijazi,

Infective Endocarditis Diagnosis and Management

HomeCirculation: Cardiovascular InterventionsVol. 6, No. 6Aortopulmonary Fistula After Transcatheter Pulmonary Valve Replacement Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBAortopulmonary Fistula After Transcatheter Pulmonary Valve Replacement Damien Kenny, MB, MD, Noa Holoshitz, MD, David Turner, MD and Ziyad M. Hijazi, MD, MPH Damien KennyDamien Kenny From the Rush Center for Congenital and Structural Heart Disease, Rush University Medical Center, Chicago, IL. , Noa HoloshitzNoa Holoshitz From the Rush Center for Congenital and Structural Heart Disease, Rush University Medical Center, Chicago, IL. , David TurnerDavid Turner From the Rush Center for Congenital and Structural Heart Disease, Rush University Medical Center, Chicago, IL. and Ziyad M. HijaziZiyad M. Hijazi From the Rush Center for Congenital and Structural Heart Disease, Rush University Medical Center, Chicago, IL. Originally published1 Dec 2013https://doi.org/10.1161/CIRCINTERVENTIONS.113.000654Circulation: Cardiovascular Interventions. 2013;6:e67–e68IntroductionA 22-year-old man with a history of a Ross procedure underwent successful transcatheter pulmonary valve replacement with a 26-mm Edwards SAPIEN valve (Edwards Lifesciences LLC, Irvine, CA) for progressive conduit dysfunction. The homograft (27 mm), placed 5 years previously, was heavily calcified with a minimum diameter of 9 mm. After demonstration of remote coronary artery position confirmed with a 24-mm Amplatzer sizing balloon (St Jude Medical, St Paul, MN), prestenting was performed with 2 P4010 stents (Cordis Corporation, Miami Lakes, FL), the first of which was covered along its entire length with expandable polytetrafluoroethylene. With wire position in the left pulmonary artery, the initial stent was mounted on an 18-mm BiB catheter (NuMed Inc, Hopkinton, NY) with postdilation with a 22-mm Atlas balloon (Bard Peripheral Vascular Inc, Tempe, AZ) to 12 atm. The second stent delivered because of recoil of the first was deployed on a 22-mm BiB with postdilation with a 24-mm Atlas (12 atm). The 26-mm valve was deployed with on a 30-mm-long balloon inflated to 5 atm after delivery with a 24 Fr Retroflex system (Edwards Lifesciences LLC). Postvalve deployment pulmonary angiography demonstrated neovalvular competence with no aneurysm of the conduit seen. Angulated ascending aortography performed routinely in our practice to assess gross coronary artery filling postvalve deployment did not identify any filling of the pulmonary arteries. Final mean pulmonary artery pressure after valve deployment was 17 mm Hg. Intracardiac echocardiography demonstrated no pulmonary incompetence with no abnormal diastolic flow seen into the main pulmonary artery (MPA). Predischarge transthoracic echocardiogram revealed a mean gradient of 12 mm Hg, and no flow was seen from the aorta into the MPA.The patient was reviewed electively 8 weeks after the procedure. He was asymptomatic; however, clinical examination revealed a new grade II continuous murmur along the upper left sternal edge. Transthoracic echocardiogram demonstrated excellent SAPIEN valve function; however, there was a small continuous jet into the MPA seen at the distal aspect of the stent complex not seen on comparable views in the postprocedural transthoracic echocardiogram. Further evaluation with computed tomography demonstrated a small aortopulmonary fistula from the ascending aorta at the branching point of the MPA into the right pulmonary artery (Figure A and B). Eight weeks later, the patient underwent successful transcatheter closure of the aortopulmonary fistula with a 6-mm Amplatzer Vascular Plug IV (St Jude Medical). This device was chosen to minimize any impingement on the SAPIEN valve. Initial hemodynamic assessment before device deployment revealed a Qp:Qs of 1.3:1, and aortogram confirmed the leak (Figure C). The defect was subsequently crossed from the ascending aorta with creation of an arteriovenous loop and balloon sizing (fistula diameter, 3.5 mm) from the femoral venous side with transesophageal echocardiography guidance (Figure D). An arteriovenous loop was chosen to provide greater stability with balloon sizing and also to extend options for device choice before closure. Device assessment confirmed the cone of the device distal to the sinotubular junction and left coronary artery. Complete closure after device release was confirmed at the end of the case (Figure E and F). The patient recovered well and was discharged home with continuation of his oral aspirin. Subsequent 3-month follow-up transthoracic echocardiogram has confirmed closure.Download figureDownload PowerPointFigure. A, Computed tomography (CT) angiogram in the axial plane demonstrating the aortopulmonary connection (white arrow) entering the main pulmonary artery above the stent complex at the junction of the main pulmonary artery with the right pulmonary artery. B, CT angiogram in the parasaggital view demonstrating the aortopulmonary connection (white arrow). C, Initial aortogram in the straight lateral view demonstrating the stented pulmonary outflow with the SAPIEN valve, the slightly dilated ascending aorta, and the posterior fistula into the distal main pulmonary artery (leak). D, Transesophageal echocardiography demonstrating short-axis view of the ascending aorta (AAO) with color Doppler assessment demonstrating leak into the pulmonary artery (white arrow). E, Final aortogram after device release demonstrating the device in a good position with no further leak. F, Three-dimensional transesophageal echocardiography demonstrating the deployed AVP IV across the fistula.Surgical management of an aortopulmonary fistula has been previously reported after transcatheter pulmonary valve replacement with a Melody valve (Medtronic Inc, Minneapolis, MN).1 Interestingly, this also occurred in a patient with a previous Ross procedure with initial assessment failing to identify the cause for postvalve implantation acute heart failure.2 Etiologic mechanisms in this case include acute trauma to the homograft in the setting of aggressive balloon dilation, as reported with patients undergoing balloon dilation of supravalvar pulmonary stenosis after arterial switch operation.3,4 Aneurysm formation, secondary to balloon dilation of the MPA distal to the covered stent, may have precipitated contact with the ascending aorta along old suture lines and subsequent fistula formation. Indeed, the use of a covered stent in this setting will not effectively mitigate against distal balloon-induced vessel trauma, and this should be evaluated effectively with repeat postvalve deployment pulmonary artery angiography, hemodynamics, and echocardiography. It is less likely that expanding the MPA with a rigid stent toward a slightly dilated ascending aorta may have precipitated contact and subsequent erosion as the fistula was several millimeters distal to the stents. However, as experience with transcatheter pulmonary valve implantation broadens, appreciation of evolving unexpected complications is essential to ensure appropriate postvalve deployment assessment and subsequent postprocedural monitoring.DisclosuresDr Hijazi works as a nonpaid consultant for Edwards Lifesciences. The other authors report no conflicts.FootnotesCorrespondence to Damien Kenny, MB, MD, Rush Center for Congenital and Structural Heart Disease, Jones 770, Rush University Medical Center, 1653 W Congress Pkwy, Chicago, IL 60612. E-mail [email protected]References1. Taggart NW, Hagler DJ, Connolly HM. Melody valve erosion into the ascending aorta.Congenit Heart Dis. 2013; 8:E64.CrossrefMedlineGoogle Scholar2. Taggart NW, Connolly HM, Hagler DJ. Acute heart failure after percutaneous pulmonary valve (Melody valve) implantation.Congenit Heart Dis. 2013; 8:E61–E63.CrossrefMedlineGoogle Scholar3. Vida VL, Biffanti R, Stellin G, Milanesi O. Iatrogenic aortopulmonary fistula occurring after pulmonary artery balloon angioplasty: a word of caution.Pediatr Cardiol. 2013; 34:1267–1268.CrossrefMedlineGoogle Scholar4. Takayama H, Sekiguchi A, Chikada M, Noma M, Ishida R. Aortopulmonary window due to balloon angioplasty after arterial switch operation.Ann Thorac Surg. 2002; 73:659–661.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Khalid Y, Dasu N, Daneshvar M, Jang P, Patel A, Dasu K, Shah A and Ercan E (2021) An Unusual Case of an Acquired Aortopulmonary Fistula after Surgical Replacement of a Bicuspid Aortic Valve, Case Reports in Cardiology, 10.1155/2021/9088024, 2021, (1-4), Online publication date: 23-Sep-2021. Gulati A, Kapoor H, Donuru A, Gala K and Parekh M (2021) Aortic Fistulas: Pathophysiologic Features, Imaging Findings, and Diagnostic Pitfalls, RadioGraphics, 10.1148/rg.2021210004, 41:5, (1335-1351), Online publication date: 1-Sep-2021. Loureiro P, Martins J, Fraisse A, Rodrigues R, Fragata J and Pinto F (2020) Iatrogenic fistula between the aorta and the right ventricular outflow tract after Melody valve implantation: Case report and literature review, Revista Portuguesa de Cardiologia, 10.1016/j.repc.2018.09.016, 39:9, (545.e1-545.e4), Online publication date: 1-Sep-2020. Loureiro P, Martins J, Fraisse A, Rodrigues R, Fragata J and Pinto F (2020) Iatrogenic fistula between the aorta and the right ventricular outflow tract after Melody valve implantation: Case report and literature review, Revista Portuguesa de Cardiologia (English Edition), 10.1016/j.repce.2018.09.013, 39:9, (545.e1-545.e4), Online publication date: 1-Sep-2020. Broda C, Mulukutla V, Bansal M, Penny D, Mullins C and Qureshi A (2020) Use of Intracardiac Echocardiography in the Evaluation and Management of Iatrogenic Aortopulmonary Communication After Percutaneous Intervention in Postoperative Patients With Congenital Heart Disease, World Journal for Pediatric and Congenital Heart Surgery, 10.1177/2150135120902117, 11:3, (338-342), Online publication date: 1-May-2020. Mallios D and Kumar S (2019) Newer advances, newer challenges?, The Journal of Thoracic and Cardiovascular Surgery, 10.1016/j.jtcvs.2018.08.074, 157:1, (e9-e10), Online publication date: 1-Jan-2019. Klassen S, Mihos C, Birmingham M, Gadoua K and Yucel E (2019) Infective Endocarditis of the Aortic Valve Complicated by Aorta–To–Pulmonary Artery Fistula, CASE, 10.1016/j.case.2019.01.004, 3:3, (110-114), Online publication date: 1-Jun-2019. Kumar T, Balduf K, Boston U and Knott-Craig C (2019) Biventricular root replacement for transcatheter pulmonary valve endocarditis after Ross operation: Double the trouble, The Journal of Thoracic and Cardiovascular Surgery, 10.1016/j.jtcvs.2018.07.111, 157:1, (e5-e7), Online publication date: 1-Jan-2019. Chongthammakun V, Mitchell M, Gudausky T, Bartz P and Foerster S (2019) Cardiac Arrest Secondary to Traumatic Aortopulmonary Window During Transcatheter Pulmonary Valve Implantation in Supported Ross, JACC: Case Reports, 10.1016/j.jaccas.2019.10.017, 1:5, (746-750), Online publication date: 1-Dec-2019. Gregory S, Zoller J, Shahanavaz S, Chilson K and Ridley C (2018) Anesthetic Considerations for Transcatheter Pulmonary Valve Replacement, Journal of Cardiothoracic and Vascular Anesthesia, 10.1053/j.jvca.2017.06.002, 32:1, (402-411), Online publication date: 1-Feb-2018. Holzer R, Suradi H and Hijazi Z (2018) Valve Interventions in the Young Adult With Heart Failure Heart Failure in the Child and Young Adult, 10.1016/B978-0-12-802393-8.00049-1, (655-674), . Holzer R and Hijazi Z (2015) Transcatheter pulmonary valve replacement: State of the art, Catheterization and Cardiovascular Interventions, 10.1002/ccd.26263, 87:1, (117-128), Online publication date: 1-Jan-2016. Muller B, Ghawi H, Heitschmidt M, Fogg L, Hibbeln J, Hijazi Z and Kenny D (2015) Medium-term CT evaluation of stent geometry, integrity, and valve function of the Edwards SAPIEN transcatheter heart valve in the pulmonary position, Catheterization and Cardiovascular Interventions, 10.1002/ccd.26074, 87:3, (E97-E103), Online publication date: 15-Feb-2016. Torres A, Sanders S, Vincent J, El-Said H, Leahy R, Padera R and McElhinney D (2015) Iatrogenic aortopulmonary communications after transcatheter interventions on the right ventricular outflow tract or pulmonary artery: Pathophysiologic, diagnostic, and management considerations, Catheterization and Cardiovascular Interventions, 10.1002/ccd.25897, 86:3, (438-452), Online publication date: 1-Sep-2015. Gillespie M, McElhinney D, Kreutzer J, Hellenbrand W, El-Said H, Ewert P, Rhodes J, Søndergaard L and Jones T (2015) Transcatheter Pulmonary Valve Replacement for Right Ventricular Outflow Tract Conduit Dysfunction After the Ross Procedure, The Annals of Thoracic Surgery, 10.1016/j.athoracsur.2015.04.108, 100:3, (996-1003), Online publication date: 1-Sep-2015. December 2013Vol 6, Issue 6 Advertisement Article InformationMetrics © 2013 American Heart Association, Inc.https://doi.org/10.1161/CIRCINTERVENTIONS.113.000654PMID: 24347658 Manuscript receivedJuly 1, 2013Manuscript acceptedSeptember 24, 2013Originally publishedDecember 1, 2013 Keywordsfistuladevice closuretranscatheterpulmonary valvePDF download Advertisement SubjectsCatheter-Based Coronary and Valvular Interventions