The correct answer is: c. Percutaneous closure

This patient has a clinical and image findings corresponding with an aorto-atrial fistula, years after the surgery for endocarditis. Fistulas between aorta and cardiac cavities after infective endocarditis are rare. These aorto-cavitary communications create intra-cardiac shunts, which may result in clinical deterioration.^1,2 Although surgery was the treatment by default years ago, such therapeutic option may carry serious complications and the mortality could be high.³ Percutaneous treatment represents an attractive alternative and the improvement of recent occlusion devices has placed this technique in the first line for the treatment of these defects.⁴ In this case, using right femoral approach we were able to cross the defect and we deployed two Amplatzer Vascular Plug III occluders. Monitorization with real-time 3D transesophageal echocardiography showed a marked decrease in the shunt magnitude and that both devices did not interfere with the mitral valve or aortic prosthetic valve function. On clinical follow-up, the patient is asymptomatic and echocardiographic controls revealed significantly decrease in the size of cardiac cavities.

References

1. Anguera I, Miro JM, Vilacosta I et al. Aorto-cavitary fistulous tract formation in infective endocarditis: clinical and echocardiographic features of 76 cases and risk factors for mortality. Eur Heart J 2005:288-97.
2. Anguera I, Miro JM, San Roman JA et al. Periannular complications in infective endocarditis involving prosthetic aortic valves. Am J Cardiol 2006:1261-8.
3. Ananthasubramaniam K. Clinical and echocardiographic features of aorto-atrial fistulas. Cardiovasc Ultrasound 2005:1.
4. Lu TL, Beregi JP, Rey C, Midulla M, Lions C. Percutaneous closure of an aorto-right ventricular fistula with an Amplatzer plug. J Vasc Interv Radiol 2011:100-1.