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.
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.