scholarly journals P1471 Aortic, mitral and tricuspid valve transcatheter therapy in patient with severe chronic heart failure

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
B M Szlosarczyk ◽  
K Golinska-Grzybala ◽  
J Rzucidlo-Resil ◽  
J Trebacz ◽  
M Stapor ◽  
...  
Keyword(s):  
Heart Failure ◽  
Cardiac Surgery ◽  
Heart Disease ◽  
Aortic Valve ◽  
Tricuspid Valve ◽  
Percutaneous Treatment ◽  
Paravalvular Leak ◽  
Heart Team ◽  
Promising Alternative ◽  
Valvular Heart Diseases

Abstract Introduction The objective of this case is to present a novel approach in percutaneous treatment of complex valvular heart disease in patient disqualified from cardiac surgery. Case Description A 59 year-old-man with a history coronary heart disease, myocardial infarctions (in 1993, 2011), percutaneous right coronary angioplasty (2011,2012), chronic kidney disease, persistent atrial flutter, Hodgkin"s lymphoma treated with radiotherapy and chemotherapy, was admitted to hospital due to congestive heart failure in NYHA class IV, despite optimal, maximal tolerated pharmacological treatment (furosemide 40 mg tid, torasemide 20 mg qd, bisoprolol 5 mg qd, perindopril 5 mg qd, spironolactone 25 mg qd, acetylsalicylic acid 75 mg qd, atorvastatin 40 mg qd) Physical examination showed BMI tachycardia 110/sec, blood pressure 95/68 mmHG, systolic murmur grade 5/6 best heard at the apex, moderate leg oedema. Chest auscultation revealed crepitations. Echocardiography revealed severe, functional mitral (MR) - 4+(VC 8/20 mm) and tricuspid (TR) regurgitation (4+); combined aortic valve disease (moderate stenosis (SA), mild regurgitation (AR) - SA max. grad. 39/23mmHg, valve area -1.3-1.4 cm2, LV end diastolic diameter (LVEDD)/LV end-systolic diameter (LVESD) 57/44 mm, LV ejection fraction 48%, both atrium enlargement (left atrium 38 cm2, right atrium 35 cm2). Angiography didn`t show significant changes in coronary arteries. Because of high surgical risk (Euroscore II 9,14%, STS 7,29%) and porcelain aorta confirmed in CT scan Heart Team disqualified patient from cardiac surgery (mitral and aortic valve replacement and tricuspid valve annuloplasty). Afterward he was qualified to complex, percutaneous treatment – TAVI (trans-aortic valve implantation) in first stage, and transcatheter Mitraclip and Triclip implantation in second stage. The Portico transcatheter aortic valve (29mm) was implanted – max. grad. was 11 mmHg, residual small paravalvular leak was noted. Two weeks later transcatheter Mitraclip and Triclip implantation was performed and significant reduction of both MR (2+/3+) and TR (2+) was observed. Gradually after percutaneous treatment dyspnoea improved to class NYHA I/II and one month later patient was discharged to home. Discussion Percutaneous treatment of valvular heart diseases becomes a promising alternative for patients disqualified from cardiac surgery.

scholarly journals Valvular heart disease in autoimmune diseases in Mexico

2021 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
J Aceituno Melgar ◽  
JF Fritche-Salazar ◽  
ME Soto-Lopez
Keyword(s):  
Heart Disease ◽  
Mitral Valve ◽  
Aortic Valve ◽  
Aortic Stenosis ◽  
Autoimmune Diseases ◽  
Tricuspid Valve ◽  
Tricuspid Regurgitation ◽  
Valvular Heart Disease ◽  
Valve Disease ◽  
Calcium Deposit

Abstract Funding Acknowledgements Type of funding sources: None. Background  The autoimmune diseases (AD) have high morbidity and mortality due to their affection to the heart. Purpose Our objective was to describe the valvular heart disease (VHD) in patients with AD. Methods Patients with systemic lupus erythematous (SLE), rheumatoid arthritis (RA), and systemic sclerosis (SS) diagnosis were included, from January 1st 2008 to December 31th 2018. Prevalence rates of valve involvement were calculated. Results A total of 163 patients (57.6% with SLE, 23.3% with RA, 19.0% with SS) were included. The global prevalence of VHD was 5.4% in SLS, 23.6% en RA, and 15.9% in SS. The more affected valve in SLS was the tricuspid valve in 24% (12% with severe tricuspid regurgitation (STR), p = 0.028), in RA was the aortic valve in 26% (13% with severe aortic stenosis (SAS), p = 0.02), and with SS was the tricuspid valve in 48% (29% with moderate tricuspid regurgitation (MTR)). The calcium deposit was present in 66% in RA (37% in aortic valve, p < 0.001). The valve thickening (>5 mm) was higher in RA (50%, p < 0.001), with predominance in mitral valve (26%). Conclusions We found significant higher rates of STR in SLE, SAS in RA, and MTR in SS compared with the literature. Moreover, calcification and valve thickening were found more often in RA. Early diagnosis of subclinical VHD is mandatory to improve the long-term prognosis of these patients. Valvular heart disease. Autoimmune Disease (n = 163) P value* SLE (n = 94) RA (n = 38) ES (n = 31) Demographic characteristics Age, years. Gender, Male / Female, n Body Mass Index (kg/m2) Arterial hypertension, n (%) Diabetes Mellitus, n (%) 38.8 (12.6) 9/85 26.2 (5.9) 21(22.3%) 6 (6.3%) 62.45 (12.3) 7/31 26.6 (7.1) 14(36.8%) 4 (10.5%) 53.8 (13.3) 2/29 25.4 (4.7) 12 (38.7) 5 (16.1%) <0.001 NS NS NS NS Echocardiographic findings. Valve thickening Aortic Mitral 8 (9%) 1 (1%) 7 (7%) 19 (50%) 9 (24%) 10 (26%) 1 (3%) 0 1 (3%) <0.001 Calcium Deposit Aortic Mitral 4 (4%) 2 (2%) 2 (2%) 25 (66%) 14 (37%) 11 (29%) 8 (26%) 4 (12.8%) 4 (12.9%) <0.001 Aortic valve disease 4 (4%) 10 (26%) 0 Aortic stenosis Moderate Severe 0 0 0 7 (18%) 2 (5%) 5 (13%) 0 0 0 0,02 Moderate Aortic Regurgitation 4 (4%) 3 (8%) 0 NS Mitral valve disease 8 (9%) 2 (5%) 2 (6%) Mitral stenosis Moderate Severe 4 (4%) 2 (2%) 2 (2%) 1 (3%) 0 1 (3%) 1 (3%) 0 1 (3%) NS Mitral Regurgitation Moderate Severe 4 (4%) 2 (2%) 2 (2%) 1 (3%) 0 1 (3%) 1 (3%) 0 1 (3%) NS Tricuspid Regurgitation Moderate Severe 22 (24%) 11 (12%) 11 (12%) 8 (21%) 7 (18%) 1 (3%) 15 (48%) 9 (29%) 6 (19%) 0,028 Pulmonic valve disease Moderate Pulmonic Stenosis Moderate Pulmonic Regurgitation 6 (6%) 1 (1%) 5 (5%) 1 (3%) 0 1 (3%) 0 0 0 NS * Not Significant.

scholarly journals Aortic Valve Neocuspidization Using Autologous Pericardium (Ozaki Procedure): an Alternative to Aortic Valve Replacement in Adult Cardiac Surgery?

2021 ◽  
Author(s):  
Luca Koechlin ◽  
Friedrich S. Eckstein
Keyword(s):  
Cardiac Surgery ◽  
Aortic Valve ◽  
Aortic Valve Replacement ◽  
Valve Replacement ◽  
Pacemaker Implantation ◽  
Unmet Need ◽  
Heart Team ◽  
Autologous Pericardium ◽  
Potential Benefits ◽  
Adult Cardiac Surgery

Abstract Purpose of the Review The aim of this article is to describe the technique of aortic valve neocuspidization using autologous pericardium (AVNeo, “OZAKI procedure”) in adult cardiac surgery, to analyze recent findings, and to discuss benefits and limitations of this technique. Recent Findings Potential benefits of this technique include excellent hemodynamic performances, minimal use of foreign material, low rates of permanent pacemaker implantation, and omission of oral anticoagulation. However, data regarding the durability of the procedure are hitherto limited, and the procedure is associated with a higher complexity compared to aortic valve replacement. Summary AVNeo using autologous pericardium in adult cardiac surgery is a promising technique providing several benefits. However, there is a major unmet need for more data, especially regarding long-term durability. Thus, based on currently available data, we recommend careful patient selection within the heart team and shared decision-making with the informed patient.

scholarly journals Surgical Explantation of Transcatheter Aortic Valve Bioprostheses

2021 ◽  
Vol 14 (4) ◽  
Author(s):  
Alexander A. Brescia ◽  
G. Michael Deeb ◽  
Stephane Leung Wai Sang ◽  
Daizo Tanaka ◽  
P. Michael Grossman ◽  
...  
Keyword(s):  
Cardiac Surgery ◽  
Aortic Valve ◽  
Operative Mortality ◽  
Artery Bypass ◽  
Paravalvular Leak ◽  
Transcatheter Aortic Valve ◽  
Risk Of Mortality ◽  
Risk Patients ◽  
Transcatheter Valve ◽  
Predicted Risk

Background: Despite the rapid adoption of transcatheter aortic valve replacement (TAVR) since its initial approval in 2011, the frequency and outcomes of surgical explantation of TAVR devices (TAVR-explant) is poorly understood. Methods: Patients undergoing TAVR-explant between January 2012 and June 2020 at 33 hospitals in Michigan were identified in the Society of Thoracic Surgeons Database and linked to index TAVR data from the Transcatheter Valve Therapy Registry through a statewide quality collaborative. The primary outcome was operative mortality. Indications for TAVR-explant, contraindications to redo TAVR, operative data, and outcomes were collected from Society of Thoracic Surgeons and Transcatheter Valve Therapy databases. Baseline Society of Thoracic Surgeons Predicted Risk of Mortality was compared between index TAVR and TAVR-explant. Results: Twenty-four surgeons at 12 hospitals performed TAVR-explants in 46 patients (median age, 73). The frequency of TAVR-explant was 0.4%, and the number of explants increased annually. Median time to TAVR-explant was 139 days and among known device types explanted, most were self-expanding valves (29/41, 71%). Common indications for TAVR-explant were procedure-related failure (35%), paravalvular leak (28%), and need for other cardiac surgery (26%). Contraindications to redo TAVR included need for other cardiac surgery (28%), unsuitable noncoronary anatomy (13%), coronary obstruction (11%), and endocarditis (11%). Overall, 65% (30/46) of patients underwent concomitant procedures, including aortic repair/replacement in 33% (n=15), mitral surgery in 22% (n=10), and coronary artery bypass grafting in 16% (n=7). The median Society of Thoracic Surgeons Predicted Risk of Mortality was 4.2% at index TAVR and 9.3% at TAVR-explant ( P =0.001). Operative mortality was 20% (9/46) and 76% (35/46) of patients had in-hospital complications. Of patients alive at discharge, 37% (17/37) were discharged home and overall 3-month survival was 73±14%. Conclusions: TAVR-explant is rare but increasing, and its clinical impact is substantial. As the utilization of TAVR expands into younger and lower-risk patients, providers should consider the potential for future TAVR-explant during selection of an initial valve strategy.

scholarly journals Heart failure requiring hospitalization in patients after cardiac surgery for valvular heart disease

2019 ◽  
Vol 26 (2) ◽  
pp. 57-62
Author(s):  
A. V. Zhadan
Keyword(s):  
Heart Failure ◽  
Cardiac Surgery ◽  
Heart Disease ◽  
Valvular Heart Disease ◽  
Heart Valves ◽  
Reverse Remodeling ◽  
Damage Indicators ◽  
Heart Pathology ◽  
Permanent Form

The aim – to determine the factors associated with the frequency of hospitalizations for decompensation of heart failure (HF) after cardiac surgery in patients with valvular heart disease. Materials and methods. 235 patients who underwent cardiac surgery for valvular heart disease were examined. During the period from 2014 to 2017, a part of patients (129 people) had no hospitalizations, while 106 people were on inpatient treatment from 1 to 10 times, on average 2.78±1.95. The complex of examination of patients along with physical examination included electrocardiography, echocardiography. Results and discussion. During dynamic observation for 2 years in the group of patients without hospitalization, a progressive statistically significant decrease in the size of the left atrium (LA) and left ventricle (LV) as well as an increase in LV contractility were noted, while in the group of patients after hospitalization such changes were not observed. The dimensions of the chambers of the heart remained practically unchanged for 2 years. Thus, it can be concluded that the more severe course of heart failure after prosthetics of heart valves is accompanied by the absence of reverse remodeling of the heart chambers. Predictors of hospitalizations for HF are the presence of diabetes mellitus, hypertension and permanent form of atrial fibrillation. Conclusions. The probability of progression of heart failure in patients after cardiosurgical intervention for valvular heart pathology is not affected by sex, age, type of lesion of the valve, etiology of valve damage, indicators of echocardiography. Predictors of hospitalizations for heart faiure in the long-term postoperative period are the presence of diabetes, AF, and AH. The more severe course of heart failure after prosthetics of heart valves is accompanied by the absence of reverse remodeling of the heart chambers.

P6508Percutaneous versus surgical paravalvular leak: a ten-year tertiary centre experience

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
G Sa Mendes ◽  
R Teles ◽  
J Neves ◽  
M Trabulo ◽  
M Almeida ◽  
...  
Keyword(s):  
Heart Failure ◽  
Open Heart Surgery ◽  
Percutaneous Closure ◽  
Paravalvular Leak ◽  
P Value ◽  
Percutaneous Technique ◽  
High Risk Population ◽  
Heart Team ◽  
Technical Success ◽  
Significant Difference

Abstract Aims Paravalvular leak (PVL) presents an incidence ranging from 2–17%. Open heart surgery is considered the standard treatment and there is no consensus regarding the role of percutaneous closure of non-endocarditis PVL. Methods Single-centre retrospective study including consecutive patients that had their PVL closed percutaneously or by surgery, after heart team agreement, between 2007 and 2018. The primary goal was to assess mortality and rehospitalizations. The secondary goals were: a) the technical success, defined as reduction in regurgitation [≥1 degree] and b) clinic and laboratorial improvement. Results Forty-eight patients were included (mean age of 66±13 years, 56% male), 12 submitted to percutaneous closure and 36 to surgery (74 vs 65 years, p=0,026, respectively), with similar gender distribution. 56% had an aortic PVL, with the remainder having a mitral leak, with no difference between groups. The indications were heart failure in 91% and haemolytic anaemia in 42%. A combination of both indications and NYHA heart failure functional class ≥ III were higher in percutaneous group. The severity of leak was comparable in both groups. Patients treated percutaneously had a significant higher rate of atrial fibrillation (92% vs 42%), COPD (33% vs 3%), peripheral artery disease (58% vs 22%) and higher EuroScore II (13,1% [7,1 - 19,0 CI 95%] vs 4,1 [2,9 - 6,5 CI 95%], p=0,003). There was no significant difference between groups with respect to all- cause mortality at 6 months, and to cardiovascular (CV) mortality and CV rehospitalization at 1-year follow-up. The technical success was lower in percutaneous group, but clinic and laboratorial results did not differ (table). Primary and secondary [(a) tecnical success (b) clinical and laboratorial improvements] endpoints of percutaneous vs surgery paravalvular leak closure Percutaneous PVL closure Surgical PVL Closure p-value Mortality @ 6 M 17% 25% p=1.000 CV Mortality @ 12 M 25% 31% p=1.000 Rehospitalization @ 12 M 18% 21% p=0.694 Technical success (a) 75% 97% p=0.043 NYHA improvement (b) 70% 71% p=0.171 Hb improvement (b) mean Δ: 1.2±1.1 g/dl mean Δ: 1.3±2.5 g/dl p=0.737 LDH reduction (b) mean Δ: −682±828 U/L mean Δ: −473±1215 U/L p=0.577 Conclusions In this high-risk population, clinical and laboratorial improvement was achieved by both methods. The percutaneous technique seems more appropriate for patients with higher risk, despite a lower technical success in the reduction of the severity of the leak.

scholarly journals Healthcare utilization in clinically significant tricuspid regurgitation patients with and without heart failure

2020 ◽  
Author(s):  
Colin M Barker ◽  
David P Cork ◽  
Peter A McCullough ◽  
Hirsch S Mehta ◽  
Joanna Van Houten ◽  
...  
Keyword(s):  
Heart Failure ◽  
Heart Disease ◽  
Healthcare Utilization ◽  
Tricuspid Valve ◽  
Tricuspid Regurgitation ◽  
Valve Disease ◽  
Clinically Significant ◽  
Hospital Days

Aim: This study evaluated how the presence of right-sided heart disease (RSHD), other valve disease (OVD) and heart failure (HF) impacts healthcare utilization in patients with tricuspid valve disease (tricuspid regurgitation [TR]). Materials & methods: Of the 33,686 patients with TR: 6618 (19.6%) had TR-only; 8952 (26.6%) had TR with HF; 12,367 (36.7%) had TR with OVD but no HF; and 5749 (17.1%) had TR with RSHD only. Results: The presence of RSHD, OVD or HF in patients with TR was independently associated with increased annualized hospitalizations, hospital days and costs relative to patients with TR alone. Conclusion: All three co-morbidities were associated with increased healthcare utilization, with HF showing the greatest impact across all measures.

scholarly journals Prevalence and patterns of coronary artery disease in patients undergoing cardiac surgery for rheumatic and non- rheumatic valvular heart disease in a tertiary care center of Nepal

2018 ◽  
Vol 15 (2) ◽  
pp. 21-24
Author(s):  
Ravi Sahi ◽  
Arun Sayami ◽  
Ratna Mani Gajurel ◽  
Chandra Mani Poudel ◽  
Hemant Shrestha ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Cardiac Surgery ◽  
Heart Disease ◽  
Coronary Artery ◽  
Valvular Heart Disease ◽  
Tertiary Care ◽  
Vessel Disease ◽  
Cardiovascular Morbidity And Mortality ◽  
Valvular Heart Diseases ◽  
Artery Disease

Background and Aims: Coronary artery disease (CAD) constitute a major cause of cardiovascular morbidity and mortality worldwide with an enormous burden on healthcare resources. Prevalence and pattern of CAD in patients of rheumatic and non-rhemuatic valvular heart diseases varies widely with limited data on optimal strategies for diagnosis and treatment.Methods: This study includes 97 patients with rheumatic and non-rheumatic valvular heart disease who underwent coronary angiogram (CAG) before cardiac surgery. Patients were divided into two groups based on rheumatic heart disease (RHD) & non-rheumatic disease (Non-RHD) and correlate the patterns of CAD.Results: Out of 97 patients, 22 (22.6%) patients were found to have significant CAD. In patients with non-rheumatic origin CAD was common (15 patients, 68.1%) as compared to rheumatic origin (7 patients, 31. 8%). In rheumatic origin, the prevalence was 7(12.2%) out of 57 patients while in non-rheumatic origin, was 15(37.5%) out of 40 patients. In RHD group, all patients with CAD were found to have single vessel diease (SVD) while, in non-RHD group, 11 patients (73.3%) had SVD, 3 patients (16.7%) had double vessel disease (DVD) and one patient (5.6%) had triple vessel disease (TVD).Conclusions: Prevalence of CAD is higher in patients with non-RHD in comparison to those with RHD. We also found SVD to be the most common pattern of CAD in both rheumatic and non-rheumatic valvular heart disease.

Incidence and Risk Distribution of Heart Failure in Adolescents and Adults With Congenital Heart Disease After Cardiac Surgery

2006 ◽  
Vol 97 (8) ◽  
pp. 1238-1243 ◽  
Author(s):  
Kambiz Norozi ◽  
Armin Wessel ◽  
Valentin Alpers ◽  
Jan Ole Arnhold ◽  
Siegfried Geyer ◽  
...  
Keyword(s):  
Heart Failure ◽  
Congenital Heart Disease ◽  
Cardiac Surgery ◽  
Heart Disease ◽  
Congenital Heart ◽  
Risk Distribution ◽  
Adolescents And Adults

scholarly journals DIAGNOSTICS AND INTENSIVE CARE OF HEART FAILURE IN PATIENTS WHO UNDERWENT CORONARY ARTERY BYPASS GRAFT SURGERY WITH ARTIFICIAL CIRCULATION

2021 ◽  
Vol 4 (18) ◽  
pp. 4-9
Author(s):  
V.I. Cherniy ◽  
Y.V. Kurylenko
Keyword(s):  
Heart Failure ◽  
Coronary Heart Disease ◽  
Cardiac Surgery ◽  
Heart Disease ◽  
Coronary Artery ◽  
Coronary Artery Bypass Grafting ◽  
Coronary Artery Bypass ◽  
Artery Bypass ◽  
Bypass Grafting ◽  
Artificial Circulation

Abstract. Introduction. Coronary heart disease, the complexity of the surgery conducted, inflammatory reaction to extracorporeal circulation and the need for perioperative anticoagulation influence perioperative state of hemodynamics during the surgical revascularization of a myocardium in patients with coronary heart disease. The aim. To improve the results of treatment of cardiac surgery patients with heart failure who underwent surgery, namely, coronary artery bypass grafting using extracorporeal circulation by improving methods of diagnosing heart failure. Materials and methods. 100 cardiac surgery patients with coronary heart disease were operated on at State Institution of Science “Research and Practical Center of Preventive and Clinical Medicine” State Administrative Department. In all the cases, coronary artery bypass grafting was performed using artificial circulation. In patients of group 1 (40 patients) in the postoperative period, the correction of hemodynamic disorders was performed according to the standard protocol. In group 2 (60 patients) - a differentiated approach to the correction of hemodynamic disorders was used. Results. It was found that in group 2 for stabilization of hemodynamics, oxygen status, microcirculation, smaller doses of sympathomimetics and shorter duration of their use, P <0.05 than in 1 were applied. Conclusions. The results of the studies indicate the possibility of using the method of phasography, in particular, the analysis of symmetry of the T wave, as a marker of ischemic changes in the myocardium in cardiac patients who underwent coronary artery bypass grafting using artificial circulation. The obtained data show that the developed algorithm of perioperative management of cardiac surgery patients with heart failure makes it possible to significantly accelerate the rehabilitation of cardiac surgery patients, increase patient comfort and reduce the length of their hospitalization. The possibility of using phasography for monitoring of myocardial condition in patients undergoing coronary artery bypass surgery has been investigated.

scholarly journals Complex cardiac surgery in a high-risk patient with new-onset severe mitral regurgitation and aorta to right ventricular fistula after transcatheter aortic valve implantation: a case report

2020 ◽  
Vol 4 (5) ◽  
pp. 1-5
Author(s):  
Mario Verdugo-Marchese ◽  
Pierre Monney ◽  
Olivier Muller ◽  
Matthias Kirsch
Keyword(s):  
Heart Failure ◽  
Cardiac Surgery ◽  
High Risk ◽  
Aortic Valve ◽  
Right Ventricular ◽  
Left Ventricular ◽  
Transcatheter Aortic Valve ◽  
Risk Patients ◽  
Aortic Valve Implantation ◽  
Valve Implantation

Abstract Background Transcatheter aortic valve implantation (TAVI) is the procedure of choice for aortic stenosis in high surgical risk patients, but it is no free from complications. Case summary A 86-year-old patient with severe aortic stenosis underwent TAVI 3 years ago with an Edwards Sapiens valve by femoral access. In the echocardiography follow-up, an aorta–right ventricular (Ao-RV) fistula was noted with restrictive flow and no significant shunt and it was treated conservatively. Three years after TAVI, the patient underwent cardiac surgery because of worsening heart failure due to a severe degenerative mitral regurgitation with tethering of P2 due to left ventricular remodelling, a posterior jet of severe regurgitation, and left ventricular dilatation. Surgical replacement of the TAVI and aortic root with a bioprosthesis (Medtronic Freestyle) and direct closure of the fistula was performed along with the mitral valve replacement. The patient was discharged with a good clinical result and no evidence of remaining Ao-RV fistula at transthoracic echocardiography. Discussion Aorta–right ventricular fistula is a rare entity. Most reported cases arise after rupture of a congenital coronary sinus aneurism, endocarditis, trauma, and aortic valve or aortic root surgery. This is the 10th reported case after TAVI (9 after an Edwards Sapiens TAVI). Non-significant shunt can be treated conservatively but development of heart failure and death are described in significant shunts. Balloon post-dilatation and the absence of surgical calcium debridement inherent to TAVI may theoretically contribute to the development of the fistula. Surgical replacement and closure of the fistula is a therapeutic option for this entity even in high-risk patients.

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