Cutaneo-Pericardial Fistula After Transapical Approach for Transcatheter Aortic Valve Replacement.

A 77-year-old male with severe aortic stenosis, prior coronary artery bypass graft, recurrent infective endocarditis, and chronic Q fever (taking hydroxychloroquine and doxycycline) underwent a transcatheter aortic valve replacement (TAVR) by the transapical (TA) approach via left thoracotomy. A 29-mm Edwards SAPIEN XT valve (Edwards Lifesciences, Irvine, California) was successfully deployed using the Ascendra 2 delivery system (Edwards Lifesciences). Purse-string sutures were placed at the left ventricular (LV) apex. Post-procedure development of a hemorrhagic pericardial effusion necessitated surgical re-exploration; bleeding from the LV apex was controlled with placement of pledgeted purse-string sutures. Further post-procedure recovery was complicated by gram-negative pneumonia (Serratia marcescens and Klebsiella pneumoniae) that improved with levofloxacin. Two months later, the patient complained of swelling above the incision site. Chest computed tomography demonstrated a hematoma that was managed conservatively (Figure 1A). Four months following TAVR, the patient developed a necrotic skin lesion with wound drainage (Figure 1B). Repeat computed tomography showed extravasation of contrast through the LV apex into the surrounding soft tissue and a fluid collection within the chest wall consistent with a LV apical