Aorto-Right Ventricular Fistula Post-Transcatheter Aortic Valve Replacement: Multimodality Imaging of Successful Percutaneous Closure

Transcatheter aortic valve replacement (TAVR) has transformed aortic stenosis therapy, with greater than 200,000 procedures performed worldwide since the first case was performed by the French interventional cardiologist Alain Cribier in 2002. One rare but dreaded complication is aortic periannular rupture, seen in less than 1% of all TAVR procedures. Although TAVR is a safe procedure, with an average national in-hospital mortality of less than 4%, complications may still occur. Aortic periannular rupture post-TAVR refers to a spectrum of injuries that occur in the aortic root and left ventricular outflow tract (LVOT) region and portend a poor prognosis. It has been described as having four types: supra-annular, intra-annular, subannular, and combined. These ruptures often lead to flow of blood into the pericardial space, which may lead to pericardial tamponade. We describe a case of aorto-right ventricular (RV) fistula post-TAVR that is unique due to its flow pathway, Doppler findings, and lack of rupture into the pericardial space. Using a multimodality imaging approach for diagnosis and preprocedure planning, the rupture defect was successfully eliminated by percutaneous implantation of one Amplazter vascular plug (AVP) intravenous (IV) device (St. Jude Medical, St. Paul, MN). To our knowledge, this is the first reported case of the successful use of a plugging device for this type of disease.