2. Tessitoe N, Mansueto G, Lipari G, et al. Endovascular versus surgical preemptive repair for forearm arteriovenous ﬁstula juxta-anastomotic ste- nosis: analysis of data collected prospectively from 1999-2004. Clin J Am Nephrol 2006; 1:448 – 454. fault fault fault fault Percutaneous Closure of an Aorto–right Ventricular Fistula with an Amplatzer Plug From: Tri-Linh Lu, MD Jean-Paul Beregi, MD, PhD Christian Rey, MD Marco Midulla, MD Christophe Lions, MD Service de Radiologie (T.-L.L., J.-P.B., M.M., C.L.) Service de Cardiologie infantile (C.R.) Hôpital Cardiologique CHRU Lille Boulevard Pr Leclerc 59037 Lille, France Editor: Fistulas between aorta and cardiac cavities are rare. Often associated with trauma, such ﬁstulas may also be seen in patients with valvular replacement, endocarditis, or the rupture of an aneurysm of the Valsalva sinus. These patho- logic communications are highly morbid and lead to hemo- dynamic instability secondary to the shunt effect (1). His- torically, the treatment has been based on surgical repair (2). Nevertheless, with the advance of endovascular tech- nologies, more and more emphasis is now placed on per- cutaneous closure. A 50-year-old man was admitted to the intensive care unit in septic shock. He previously underwent an aortic valve replacement 7 years before because of endocarditis. Our institutional review board does not require approval for anonymous case reports; the patient gave his permission for publication. An initial helical computed tomography (CT) scan showed a pathologic 9.0  6.5 cm wide neocavity in the vicinity of the aortic valve replacement. There was a patent communication between the cavity and the right ventricle (Figure 1). The pseudoaneurysm compressed the right cav- ities, giving rise to right cardiac failure. An infectious etiology was suspected, and a 6-week course of vancomycin and ceftazidime administered intra- venously was started empirically. An endovascular proce- dure was subsequently performed under local anesthesia by a right transfemoral arterial approach. Through a 6-F sheath, a right coronary Judkins sizing catheter (Cordis Corp, Miami, Florida) was inserted up to the ascending aorta. An aortogram was performed to visualize the com- munication between the ascending aorta and the pseudoan- eurysm. The origin of the ﬁstulous tract was selectively catheterized, and its diameter was measured. To occlude the ﬁstula, an 8-mm Amplatzer vascular plug (AGA Medical Corp, Plymouth, Minnesota) was placed astride the aortic wall (30% oversized). A second aortogram showed the good position of the plug and the disappearance of the shunt (Figure 2). Immediately after the procedure, the patient’s clini- cal condition improved, and his heart failure resolved. At day 3, the position of the plug was checked with a CT scan (Figure 3). The plug was in place ﬁrmly anchored in the aortic ﬁstulous tract. A thrombus in the ﬁstula became apparent. The patient was stable, and a course of observation was chosen. A ﬁnal CT scan at 4 months showed complete thrombosis of the aneurysmal ﬁstula. The ﬁstula had decreased in size (6.4  4.3 cm), and there was no further compression on the right ventricle (Figure 4). Although surgery is the primary treatment of aorto- cardiac ﬁstulas, such a therapeutic option may carry severe complications. Open procedures are risky partic- ularly with critically unstable patients. The postoperative mortality after surgical correction of a postinfectious ﬁstula can be as high as 54% (1). The anterior approach None of the authors have identiﬁed a conﬂict of interest. DOI: 10.1016/j.jvir.2010.09.019 Figure 1. Initial CT scan showing the ﬁstulous communication between the ascending aorta (a, arrow) and the right ventricle (b, arrow). Figure 2. Preprocedural and postprocedural aortograms (left anterior oblique view) showing a leak of contrast material through the ﬁstulous tract (a, arrow) and its disappearance after the successful placement of the vascular plug (b, arrow). 100  Letter to the Editor Lu et al.  JVIR