Verdugo-Marchese Mario, Monney Pierre, Muller Olivier, Kirsch Matthias
Cardiac Surgery Service, Cardiovascular Department, Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1011 Lausanne, Switzerland.
Cardiology Service, Cardiovascular Department, Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1011 Lausanne, Switzerland.
Eur Heart J Case Rep. 2020 Oct 2;4(5):1-5. doi: 10.1093/ehjcr/ytaa206. eCollection 2020 Oct.
Transcatheter aortic valve implantation (TAVI) is the procedure of choice for aortic stenosis in high surgical risk patients, but it is no free from complications.
A 86-year-old patient with severe aortic stenosis underwent TAVI 3 years ago with an Edwards Sapiens valve by femoral access. In the echocardiography follow-up, an aorta-right ventricular (Ao-RV) fistula was noted with restrictive flow and no significant shunt and it was treated conservatively. Three years after TAVI, the patient underwent cardiac surgery because of worsening heart failure due to a severe degenerative mitral regurgitation with tethering of P2 due to left ventricular remodelling, a posterior jet of severe regurgitation, and left ventricular dilatation. Surgical replacement of the TAVI and aortic root with a bioprosthesis (Medtronic Freestyle) and direct closure of the fistula was performed along with the mitral valve replacement. The patient was discharged with a good clinical result and no evidence of remaining Ao-RV fistula at transthoracic echocardiography.
Aorta-right ventricular fistula is a rare entity. Most reported cases arise after rupture of a congenital coronary sinus aneurism, endocarditis, trauma, and aortic valve or aortic root surgery. This is the 10th reported case after TAVI (9 after an Edwards Sapiens TAVI). Non-significant shunt can be treated conservatively but development of heart failure and death are described in significant shunts. Balloon post-dilatation and the absence of surgical calcium debridement inherent to TAVI may theoretically contribute to the development of the fistula. Surgical replacement and closure of the fistula is a therapeutic option for this entity even in high-risk patients.
经导管主动脉瓣植入术（TAVI）是高手术风险患者主动脉狭窄的首选治疗方法，但并非没有并发症。
一名86岁重度主动脉狭窄患者3年前经股动脉途径使用爱德华兹智慧瓣膜进行了TAVI。在超声心动图随访中，发现主动脉-右心室（Ao-RV）瘘，血流受限且无明显分流，予以保守治疗。TAVI术后3年，患者因严重退行性二尖瓣反流伴P2瓣叶因左心室重塑而受限、重度反流后向血流以及左心室扩张导致心力衰竭加重而接受心脏手术。手术中使用生物瓣膜（美敦力自由式瓣膜）置换了TAVI和主动脉根部，并直接闭合了瘘口，同时进行了二尖瓣置换术。患者出院时临床效果良好，经胸超声心动图显示无残余Ao-RV瘘的证据。
主动脉-右心室瘘是一种罕见疾病。大多数报道的病例发生在先天性冠状窦瘤破裂、心内膜炎、创伤以及主动脉瓣或主动脉根部手术后。这是TAVI术后报道的第10例病例（9例为使用爱德华兹智慧瓣膜进行TAVI术后）。无明显分流可保守治疗，但明显分流会导致心力衰竭和死亡。TAVI固有的球囊后扩张及缺乏手术去钙操作理论上可能导致瘘的发生。即使对于高危患者，手术置换并闭合瘘口也是该疾病的一种治疗选择。
