Aortic Regurgitation Following Transcatheter Closure of Aortopulmonary Window

ABSTRACT: Natural history of aortic regurgitation (AR) following transcatheter closure (TCC) of intracardiac or aortopulmonary shunt needs to be explored. AR can appear immediately or later after TCC and may increase or regress.^1,2 We describe a previously unreported AR development following successful TCC of aortopulmonary window.

J INVASIVE CARDIOL 2011;23(10):E235–E236

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Case Report

A 10-year-old boy presented with palpitation. Clinical examination revealed wide pulse pressure and grade IV/VI continuous murmur at left second intercostal space. Echocardiography demonstrated a proximal aortopulmonary window (APW) measuring 6 mm. The defect was away from the aortic valve and coronary arteries. There were no associated anomalies. The aortic valve was structurally normal and there was no aortic regurgitation (AR).

After an informed consent the patient was taken for TCC of the APW. Catheterization revealed pulmonary artery pressure of 54/36 mmHg (mean of 42 mmHg), aortic pressure of 104/58 mmHg and Qp:Qs of 2:1. An ascending aortogram in anteroposterior projection confirmed the diagnosis (Figure 1A). The defect was crossed from the aorta with a Judkins right coronary catheter and an angled-tip, 0.035-inch glide wire, which was exchanged for a 300 cm long noodle wire (AGA Medical, Plymouth, Minnesota). Crossing of APW from pulmonary end was not attempted. A stable arteriovenous wire loop was established by snaring the noodle wire from the pulmonary artery with a 15 mm gooseneck snare (Microvena Corp., White Bear Lake, Minnesota) introduced from the femoral vein. A 6 Fr Amplatzer duct-occluder delivery sheath (AGA Medical) was introduced over the wire and placed across the defect into the ascending aorta. A 10/8 mm Amplatzer duct occluder with its attached delivery cable was then inserted through the delivery sheath, and its retention disk was deployed into the ascending aorta. The entire assembly was pulled back until the aortic disk blocked the APW from the aortic side.

After confirming precise position of the device on transthoracic echocardiography and control angiography, the rest of the device was deployed on the pulmonary arterial side, by withdrawing the delivery sheath. Post-release angiogram revealed no residual shunt. However, there was new grade I mild AR (Figure 1B) that was also confirmed on color doppler echocardiography (Figure 2). Clinically no murmur was audible and aortic pulse pressure had decreased as well as pulmonary artery pressure (Aortic pressure 112/72 mmHg; pulmonary artery pressure 40/25 mmHg; mean 33 mmHg). As the defect was remote from aortic valve and there was no impingement on it, the result was accepted. On follow-up at 3 months and 6 months, patient was asymptomatic. Importantly, there was a progressive decrease in the grade of AR from mild to only trivial grade at 6 months (Figure 3).

Discussion

Functional AR could occur in structurally normal aortic valves following closure of high flow left to right shunts at aortic level. This can be explained by an acute increase in the systemic vascular resistance as a result of disconnection of the low resistance pulmonary circuit from the systemic circulation³ or due to altered geometry of the aortic root following sudden elimination of a large shunt and increased compliance.¹

The new aortic regurgitation tends to disappear on follow-up. We have encountered similar aortic regurgitation detected on color doppler echocardiography during transcatheter closure of ruptured sinus of Valsalva aneurysm too, as reported recently.⁴

References

1. Bajic S, Berden P, Podnar T. Aortic valve regurgitation following percutaneous closure of patent ductus arteriosus. Catheter Cardiovasc Interv. 2011;77(3):416-419.
2. Schoen SP, Boscheri A, Lange SA, et al. Incidence of aortic valve regurgitation and outcome after percutaneous closure of atrial septal defects and patent foramen ovale. Heart. 2008;94:844-847. 
3. Dalvi B, Goyal V, Narula D, et al. New technique using temporary balloon occlusion for transcatheter closure of patent ductus arteriosus with Gianturco coils. Catheter Cardiovasc Diagn. 1997;41:62-70.
4. Kerkar PG, Lanjewar CP, Mishra N,et al. Transcatheter closure of ruptured sinus of Valsalva aneurysm using the Amplatzer duct occluder: immediate results and mid-term follow-up. Eur Heart J. 2010;31(23):2881-2887.

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From ¹King Edward VII Memorial Hospital and Seth Gordhandas Sunderdas Medical College, KEM Hospital, Mumbai, India and ²Asian Heart Institute and Research Center, Mumbai, India.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
Manuscript submitted February 1, 2011, provisional acceptance given February 14, 2011, final version accepted February 16, 2011.
Corresponding Address: Dr. Prafulla G. Kerkar, 403, Department of cardiology, CVTC Building, KEM Hospital, Parel, Mumbai, India PIN 400012. Email: prafullakerkar@rediffmail.com