Volume 1, Issue 2, Pages (April 2017)

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Volume 1, Issue 2, Pages 70-74 (April 2017) Aorto-Right Ventricular Fistula Post-Transcatheter Aortic Valve Replacement: Multimodality Imaging of Successful Percutaneous Closure Alan F. Vainrib, MD, Homam Ibrahim, MD, Kazuhiro Hisamoto, MD, Cezar S. Staniloae, MD, Hasan Jilaihawi, MD, Ricardo J. Benenstein, MD, Larry Latson, MD, Mathew R. Williams, MD, Muhamed Saric, MD, PhD CASE Volume 1, Issue 2, Pages 70-74 (April 2017) DOI: 10.1016/j.case.2017.02.002 Copyright © 2017 American Society of Echocardiography Terms and Conditions

Figure 1 Aorto-RV fistula: TTE. (A, B) Post-TAVR TTE with color flow Doppler in the parasternal view demonstrates aorto-RV fistula with fistulous flow (arrow) from the aortic annular area to the RVOT in the long axis (A) and short axis (B). (C) Continuous wave spectral Doppler demonstrates unusual, mostly high-velocity systolic and diastolic flow between the aortic annulus and RVOT. This flow pattern argues against a ventricular septal defect where the high velocity flow would have been in systole only. CW, Continuous wave; LA, left atrium; PLAX, parasternal long axis; SAX, short axis. CASE 2017 1, 70-74DOI: (10.1016/j.case.2017.02.002) Copyright © 2017 American Society of Echocardiography Terms and Conditions

Figure 2 Aorto-RV fistula: TEE. (A, B) Post-TAVR TEE in the deep transgastric view demonstrates aorto-RV fistula represented by an echolucent channel (arrow) between the TAVR prosthesis and the RVOT on B mode (A) and color Doppler imaging (B). (C) Midesophageal short-axis view with color Doppler demonstrates fistulous flow from the aortic root into the RVOT. Note that on TEE, short-axis visualization of the defect may be more difficult than on TTE since the anteriorly located annular rupture is partly shadowed by the posteriorly located TAVR valve on TEE. This added to the challenge of TEE guidance of percutaneous closure. LA, Left atrium; PA, pulmonary artery; PV, pulmonic valve; SAX, short axis. CASE 2017 1, 70-74DOI: (10.1016/j.case.2017.02.002) Copyright © 2017 American Society of Echocardiography Terms and Conditions

Figure 3 Aorto-RV fistula: computed tomographic angiography (CTA). (A-D) Electrocardiogram-gated CTA with multiplane image reconstruction demonstrates the aorto-RV fistula. The flow originates from the right SOV (arrowhead), passes along the anterior portion of the TAVR stent, and ultimately enters the RVOT through the aorto-RV fistula defect (arrow). LA, Left atrium; LV, left ventricle; MPA, main pulmonary artery; MV, mitral valve; PV, pulmonic valve. CASE 2017 1, 70-74DOI: (10.1016/j.case.2017.02.002) Copyright © 2017 American Society of Echocardiography Terms and Conditions

Figure 4 Cine angiography during percutaneous closure of aorto-RV fistula. (A) The aorto-RV fistula was initially crossed with a multipurpose catheter and an angled wire. Subsequently, a 4-French shuttle sheath was placed through the fistula; this was confirmed with cine angiography and 3D TEE. (B) Subsequently, an 8-mm AVP 4 device was placed across the fistula. (C) Once the proper position was verified, the cable was detached and the device was deployed. CASE 2017 1, 70-74DOI: (10.1016/j.case.2017.02.002) Copyright © 2017 American Society of Echocardiography Terms and Conditions

Figure 5 Two-dimensional TEE of aorto-RV fistula closure. (A) Initially, 2D TEE in a deep gastric view confirmed crossing of a 4-French shuttle sheath through the aorto-RV fistula defect. (B) Subsequently, the RV side of AVP 4 device was deployed. (C) The AVP 4 was then pulled back, seating the device in the defect. PV, Pulmonic valve. CASE 2017 1, 70-74DOI: (10.1016/j.case.2017.02.002) Copyright © 2017 American Society of Echocardiography Terms and Conditions

Figure 6 Two-dimensional TEE of aorto-RV fistula closure: final result. (A) Biplane TEE demonstrating a well-seated AVP 4 device on both sides of the aorto-RV fistula defect. (B) Color flow Doppler confirms no residual flow across the prior site of aorto-RV fistula. LV, Left ventricle; PA, pulmonary artery. CASE 2017 1, 70-74DOI: (10.1016/j.case.2017.02.002) Copyright © 2017 American Society of Echocardiography Terms and Conditions

CASE 2017 1, 70-74DOI: (10.1016/j.case.2017.02.002) Copyright © 2017 American Society of Echocardiography Terms and Conditions