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.