Our patient is a 92-year-old male with severe aortic stenosis whose past medical history includes umbilical and inguinal hernia, chronic diastolic heart failure, right bundle branch block, coronary artery disease, and obesity. He became significantly symptomatic in the last few months prior to his admission to the hospital, where he complained of worsened dyspnea on exertion and recurrent syncopal attacks. Physical examination did not show any significant findings except for a 5/6 systolic ejection murmur in the aortic area radiating to both carotids. Diagnostic cardiac catheterization showed no evidence of coronary artery disease. Carotid Doppler showed no significant stenosis. Electrocardiogram showed sinus rhythm with a right bundle branch block. Transesophageal echocardiography showed critical aortic valve stenosis, mean pressure gradient of approximately 72 mmHg, valve area of 0.46 cm2, and left ventricular ejection fraction of 60%. A 29 mm Edwards SAPIEN XT valve was implanted via transfemoral access. Confirmation of position was then done by aortography. The transesophageal echocardiogram confirmed the adequate position of the valve with minimal aortic insufficiency. There was no pericardial effusion with normal ventricular systolic function. Postdeployment aortogram showed paravalvular leak and patent coronary arteries.\nPostdeployment hemodynamics showed zero mmHg mean gradient pressure between the left ventricle and the aorta with left ventricular end diastolic pressure (LVEDP) ~ 10 mmHg.\nPost-TAVR day 1 routine transthoracic echocardiography (TTE) showed well-seated and normally functioning bioprosthetic aortic valve with a small posterior paravalvular leak. It also showed a small-sized continuous (systolic and diastolic phases) shunt, which communicated with the aortic root into the right ventricle (aorto-RV shunt) (Figures and ).\nSince the patient was asymptomatic following the procedure, he was managed conservatively with close follow-up. His repeat TTE a month after the procedure revealed no significant change from his post-TAVR day 1 TTE (). Therefore, we decided to continue with medical management and close follow-up, since the patient was asymptomatic.\nFollow-up with TTE a year later showed persistence of the aorto-RV fistula and significant improvement in the velocity across the shunt (), which may be due to a decrease in the fistula size rather than an increase in RV pressure as RV systolic pressure (RVSP) remained within normal limits on follow-up TTE.
An 88-year-old woman, with a medical history significant for coronary artery disease, hypertension, hyperlipidemia, and known severe aortic stenosis, presented to the Structural Heart Clinic with worsening fatigue and dizziness without syncope. She had exertional dyspnea with the New York Heart Association (NYHA) Class III-IV congestive heart failure symptoms and no angina. Transthoracic echocardiogram (TTE) showed severe aortic stenosis with mean gradient of 62 mmHg and an ejection fraction (EF) of 20%. Cardiac catheterization revealed patent coronary angiogram and an aortic valve area of 0.27 cm 2.\nShe was deemed to be high risk for open heart surgery (Society of Thoracic Surgeons score 26.782%). Due to the lifestyle-limiting symptoms and severe aortic stenosis, a balloon aortic valvuloplasty was initially performed with significant improvement in symptoms (NYHA II). Computed tomography and angiography showed mildly dilated aortic arch with significant atherosclerosis but no aneurysm of the aortic root or sinus of Valsalva.\nSix months later, due to the recurrence of symptoms, she underwent successful TAVR with 26 mm SAPIEN XT bioprosthetic valve (Edwards Lifesciences, Irvine, CA, USA) using standard technique without postdeployment dilation. Proper anatomic position, trivial paravalvular leak, and normal valve function were confirmed with transesophageal echocardiogram and completion aortogram. The patient required immediate surgical repair of the utilized iliac artery. Immediately postprocedure, the patient remained largely asymptomatic with stable cardiac function (EF 55%–60%) on echocardiogram.\nThe patient had an uneventful recovery and was discharged to home on the 3rd postoperative day. TTE at 4 days and again 2 weeks after the procedure showed good positioning and functioning of the bioprosthetic valve. A new small fistula connecting the right sinus of Valsalva to the RV [Figures , and Videos , ] was noted.\nA decision was made to closely monitor the fistula and intervene if patient were to develop symptoms.\nShe was hospitalized 3 months later with worsening of heart failure symptoms. Electrocardiogram and troponins were normal. Repeat echocardiogram showed enlargement of the fistula with a velocity of >4 m/s, a Qp:Qs of 2:1, an EF reduction from 55%–60% to 30%–35%, and moderate dilation of RV. In view of the extreme risks to undergo repeat cardiac surgical procedure, including percutaneous and open closure options, the patient decided to continue with medical management for heart failure. After another admission with similar symptoms few months later, she was discharged to a skilled nursing facility with hospice care and died due to progressive heart failure. Total duration between onset of fistula and death was 9 months.