CASE PRESENTATION
A 30-year-old male patient was admitted to our institution with a
history of exertional dyspnea and palpitation for the last 4 months. On
physical examination, there was a continuous murmur heard best along the
right upper sternal border. A flow from the aorta to the right atrium
was observed in the transthoracic echocardiography (TTE) (Fig. 1A,1B).
The aortic valve was rheumatic and there was mild to moderate aortic
regurgitation. Transesophageal echocardiography (TEE) and 3D TEE
performed for additional information and revealed a shunt with a
diameter of 5.5 millimeters from the noncoronary sinus valsalva to the
right atrium (Video1; Fig. 2A, 2B). No acquired cause (infective
endocarditis, aortic or cardiac operation, etc.) was found in the
patient’s history. Therefore, it was considered as congenital ARAF. It
was decided to close because the patient had symptoms. The right femoral
artery was cannulated using a 6-F sheath, and a fistula was visualized
in the aortography (Fig. 3A). The fistula was cannulated with a 6-F
Judkins right coronary catheter, and a 0.035 inch-260 cm long
hydrophilic guidewire was advanced over the catheter from the right
atrium to the left femoral vein. The left femoral vein was cannulated
with a 6-F sheath, and an arteriovenous wire loop was created by taking
it out of the left femoral vein through a guidewire snare. The Amplatzer
Duct Occluder II (St. Jude Medical, St. Paul, Minnesota, USA) device
with the delivery system from the left femoral vein was advanced through
the sheath and inserted into the ARAF . There were no complications
related to the procedure. After the device was released, angiography of
the aortic root showed that the tunnel was completely closed(Video 2;
Fig. 3B). After the closure procedure, imaging with TTE and 3D TTE
showed that there was no residual flow and the device was in place (Fig.
4A, 4B). The symptoms of the patient decreased significantly 1 month
after the procedure.