An 86-year-old man with an history of degenerative aortic stenosis (, Video S) and treated by TAVI (Edwards Sapiens 3, 29 mm) 3 years ago, coronary artery disease (pre-TAVI coronary angiography with a 50–70% bifurcation lesion of the anterior descending involving the first diagonal branch), a permanent bicameral pacemaker implanted 6 months ago because sick sinus syndrome and arterial hypertension. In the month following the TAVI procedure, an Ao-RV fistula was noticed during a routine transthoracic echocardiography with a restrictive, non-significant shunt (, Videos S and S). No specific treatment was required and a standard pharmacological treatment with conventional clinical and echocardiography follow-up was programmed.\nDuring the last year, the patient had worsening heart failure symptoms (progressive oedema of the lower limbs, New York Heart Association dyspnoea class III, and acute pulmonary oedema episodes) which prompted multiple hospitalizations. A new severe mitral insufficiency was diagnosed at echocardiography follow-up by his cardiologist. After case review by our hospital heart team, a surgical mitral valve replacement was decided despite the complexity of the case and high perioperative risk (EUROSCORE II 28.18%, Clinical frailty scale 4/7 ‘Vulnerable’) due to the lack of other therapeutic options offering a complete treatment. He was admitted for elective surgery and patient consent was obtained before the procedure for the academic use of his clinical data. At admission, the patient had a regular cardiac rhythm a 70 b.p.m., with a pansystolic 3/6 mitral regurgitation murmur, basal bilateral pulmonary rales, a discrete lower limb oedema, and a blood pressure of 125/56 mmHg.\nThe preoperative transthoracic echocardiography confirmed a degenerative and calcified mitral valve with a posterior jet of severe regurgitation of mixed aetiology mainly due to tethering of P2 secondary to left ventricular remodelling (Carpentier classification IIIb; , Video S), a dilated left ventricle (telediastolic volume index of 97 mL/m2) with an ejection fraction of 46%, anterior wall hypokinesia (, Video S), a dilated left atrium (55 mL/m2), and a systolic pulmonary artery pressure estimated at 45 mmHg. The TAVI valve had a mean gradient of 6 mmHg and a surface of 2.2 cm2. An image consistent with an Ao-RV fistula, with restrictive continuous flow (Vmax 4.2 m/s) was noticed between the anterior aspect of the aortic valvular annulus, immediately distal to the valvular plan of the aortic prosthesis, and the right ventricular side of the interventricular septum, adjacent to crista supraventricularis with an anterior directed jet, this was coincident with annular calcifications in the base of the right coronary leaflet of the aortic valve, prior to TAVI (, , Videos S and S). A preoperative coronary angiography confirmed a severe stenosis (70–90%) of the proximal left anterior descending coronary artery (LAD) prompting the indication for coronary bypass. The mitral valve anatomy was considered not suitable for percutaneous edge to edge mitral valve repair because of severe annular calcification. The echocardiographic findings were confirmed by the intraoperative transoesophageal echocardiography (, Videos S and S) and direct surgical exploration of the diseased valve.\nThe patient underwent cardiac surgery under standard cardiopulmonary bypass (total time 156 min; aortic cross-clamp 138 min) with explantation of the TAVI (to better expose the mitral valve for replacement and the Ao-RV fistula for closure), surgical replacement of the mitral valve with a porcine stented bioprosthetic valve (St Jude Epic, size 31), coronary bypass (left internal thoracic artery to LAD), direct closure of the Ao-RV fistula (), and total aortic root replacement using a porcine stentless bioprosthetic valved aortic root (Medtronic Freestyle, size 27) because of anatomic alteration of the aortic root after TAVI explantation.\nThe patient had a standard post-operative recuperation and was transferred to a cardiac rehabilitation facility 2 weeks after surgery. Post-operative echocardiography confirmed the absence of Ao-RV and the normal function of both implanted valves (, Video S). The patient was followed in our outpatient clinic and is still doing well 2 months after the procedure.
An 89-year-old male with a prior history of laryngeal cancer status after surgical resection and radiation therapy with residual dysphagia, coronary artery disease status after coronary artery bypass grafting in 1992, severe aortic stenosis status after balloon valvuloplasty in 2013, pulmonary fibrosis, COPD on 2-liter continuous home O2 therapy, and TIA presented in our clinic with several years of progressive dyspnea and angina with exertion. He was admitted in the hospital at least five times over the past one year with chest pain and dyspnea. Diagnostic cardiac catheterization was done showing three out of four grafts being patent (SVG-RPLV completely occluded). Last year, he underwent balloon aortic valvuloplasty with a 22 mm balloon for severe aortic stenosis and the patient reported partial relief of symptoms for approximately six months after the procedure but now the symptoms are progressively getting worse. Transthoracic echocardiogram (TTE) showed concentric left ventricular hypertrophy, left ventricular ejection fraction of 60%, right ventricle mildly dilated with preserved systolic function, pulmonary artery systolic pressure of 34 mmHg, heavily calcified aortic valve annulus, mean pressure gradient of 68 mmHg, velocity of 517 cm/sec, and aortic valve area of 0.62 cm2. Cardiothoracic surgery team evaluated him for aortic valve replacement but the surgeon felt that patient is at very high risk for open-heart surgery. Per our TAVR team, his aortic valve annulus was too big (anteroposterior diameter 2.6 cm and mediolateral diameter of 2.8 cm per transesophageal echocardiogram, ) for commercially available Core Valve (Medtronic, USA). Ultimately, our TAVR team used a 29 mm Edward Sapien valve via transfemoral access. The procedure was complicated by complete heart block requiring temporary pacemaker backup. A permanent pacemaker was placed after 24 hours. Repeat TTE showed moderately dilated right ventricle with moderately reduced systolic function, pulmonary artery systolic pressure of 40 mmHg, Sapien prosthesis in aortic position with mild perivalvular leak and mean gradient of 9 mmHg, moderate sized continuous (systolic and diastolic phases) shunt which communicates with the aortic root around the prosthesis into the RV (aorto-RV shunt), and pulmonary flow (Qp) to systemic flow (Qs) ratio of 1.39. The patient was managed conservatively with close follow-up. At 30-day follow-up, the patient remained moderately to severely dyspneic. Patient was offered percutaneous closure of the aorto-RV fistula using devices like septal occluder (Amplatzer device) but patient refused it. His repeat TTE showed worsening of aorto-RV fistula and it also showed new small membranous VSD (see Video 1 in the Supplementary Material available online at ), which was not visible on the first postprocedural TTE. His condition progressively got worse. He changed his code status to comfort measures only and passed away in a couple of days.