Interventional management of an aortic root fistula after aortic-valve endocarditis

Supported by the EuroIntervention Journal

Authors

Christina Paitazoglou¹, Ulrich Lange², Jörn Sandstede³, Martin W. Bergmann¹

Case summary

Left-sided endocarditis accounts for 85% of all endocarditis cases, with perivalvular extension more common in the aortic valve endocarditis.¹ Perivalvular complications of infective endocarditis include abscess and fistulae; the frequency of fistula formation is rare (1.6-3.5%), with S. aureus being the most commonly associated organism (46%).² Additionally,  acquired aortocavital fistulas are an infrequent entity, which may occur late after an episode of endocarditis of the native aortic valve.³ 
In-hospital mortality of aortic root fistulas after endocarditis is high (41%) and they traditionally require surgical intervention.^1,2 However, percutaneous catheter closure after successful valve endocarditis treatment is a novel method for selected cases.³ This is a patient with an aortic root fistula to the right heart after past infective aortic valve endocarditis. Interventional shunt occlusion was successfully performed using a transcatheter closure device.

A 44-year-old male presented with a new continuous 3/6 grade heart murmur and exertional dyspnoea six months after past aortic valve (blood culture negative) endocarditis. He had been treated with an antibiotic regiment according to the current ESC guidelines and underwent dental surgery to eliminate chronic periodontitis believed to be the potential source of bacteraemia.

Transthoracic echocardiography revealed a left-right shunt in the aortic root from the non-coronary sinus of Valsalva into the right atrium (RA). Further evaluation included computed tomography (CT) showing the fistula in the base of the non-coronary sinus of Valsalva (Figure 1A) and an aortic angiography with confirmation of the aortic shunt and passage of a right diagnostic catheter (JR4) into the RA and right ventricle (RV) with consecutive pressure drop from 114/75 to 46/8 mmHg (Figure 1B). Left-right shunt volume calculation showed a shunt fraction of less than 20% (Qp:Qs < 1.2).
Transoesophageal echocardiography (TEE) ruled out ongoing vegetation’s (Figure 1C). Acute ongoing infective endocarditis was ruled out according to clinical judgement (no fever and signs of infection in any laboratory measurements on CRP and leucocyte count) and the modified Duke criteria for infectious endocarditis.

Untreated aortic fistulas may cause significant morbidity and lead to increased mortality due to progressive tissue destruction and once recognised, fistula closure appears to be superior to conservative management.⁴ Even though the shunt volume was small, the young patient was believed to be in danger of chronic heart failure or pulmonary hypertension, therefore interventional fistula occlusion was offered.

Images of the procedure are depicted in Figures 1D-F and supplementary material (moving images 1-5).

Following arterial puncture of the right femoral artery, the fistula was negotiated by a JR4 diagnostic catheter which allowed to place a Safari wire into the RV guided by fluoroscopy and TEE. A 6F delivery system was placed into the RV. After pre-interventional CT and TEE sizing, an Amplatzer Vascular Plug II 12mm device (Figure 1G) was securely loaded and advanced through the delivery system into the RV. Firstly, the distal disc was deployed (on the right heart side) and then the central waist and the proximal disc in the non-coronary sinus of Valsalva under constant pull. As expected from pre-interventional imaging, the device completely occluded the shunt to the RA (Figure 1F).

A two-year clinical and CT follow-up in our outpatient clinic was performed. Patient presented without heart failure or infect symptoms. CT showed the device to be in situ with total shunt occlusion (Figure 1H-I).

Conflict of interest statement

No conflicts of interest to declare.

Affiliations

1. Interventional Cardiology, Cardiologicum Hamburg, Germany
2. Asklepios Klinik Wandsbek, Hamburg, Germany
3. Radiologische Allianz, Hamburg, Germany

References

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