Percutaneous therapeutic approaches to closure of cardiac pseudoaneurysms

Cardiac and aortic pseudoaneurysms are rare complications following myocardial infarction or cardiac surgery. They are characterized by a contained cardiac or aortic rupture within surrounding tissue and have a high mortality rate if left untreated. Percutaneous treatment of cardiac pseudoaneurysms might be a feasible treatment option in patients who are at high risk of reoperative surgery. There is limited literature on the outcomes and the approaches to percutaneous treatment of these pseudoaneurysms. We review nine cases of cardiac and aortic pseudoaneurysms and percutaneous techniques for closure. Pseudoaneurysms were categorized anatomically as left ventricular posterior (posterobasal or posterolateral), left ventricular outflow tract, left ventricular apical, and ascending aortic pseudoaneurysms. Two patients with posterior pseudoaneurysms (one posterobasal treated with an Amplatzer Septal Occluder device, and one wide‐mouthed posterolateral pseudoaneurysm which was not closed, are described. We further describe two left ventricular outflow tract pseudoaneurysms treated successfully with percutaneous coil embolization, one left ventricular apical pseudoaneurysm treated with coils, and three ascending aortic pseudoaneurysms treated with a septal occluder device or vascular plug. We review the technical approaches, device selection strategies, outcomes, and complications with these percutaneous treatment options. The size of the pseudoaneurysm dimensions of its neck and relative anatomy, particularly to the coronaries and valves, are critical issues to be addressed before percutaneous treatment of these pseudoaneurysms. © 2012 Wiley Periodicals, Inc.     

Large mitral annular left ventricular pseudoaneurysm detected by cardiac magnetic resonance imaging

Although left ventricular pseudoaneurysm (LVPA) is a rare complication of mitral valve replacement, it is associated with an increased risk of rupture and consequent high mortality. It is important to establish the diagnosis of LVPA early so that definitive surgical therapy can be administered. Cardiac magnetic resonance imaging provides an accurate preoperative evaluation that may be useful in the routine evaluation of suspected LVPA cases.     

Transcatheter closure of left ventricular pseudoaneurysm

Left ventricular pseudoaneurysm is a rare complication of myocardial infarction, cardiovascular surgery, trauma, or infection. Untreated left ventricular pseudoaneurysm can have significant morbidity and mortality. Surgical treatment has generally been the standard of care. However, with a sicker and older population, surgical risks can sometimes be significant. We report a case of successful percutaneous closure of left ventricular pseudoaneurysm using coils and a vascular plug. We emphasize the role and importance of multimodality imaging for accurate diagnosis and therapy, and briefly review the literature on the various approaches used for percutaneous closure of left ventricular pseudoaneurysms.     

Transapical percutaneous closure of rapidly expanding post‐surgical left ventricular outflow tract pseudoaneurysm

Left ventricular pseudoaneurysm is an infrequent but potentially fatal complication following cardiac surgery, with spontaneous rupture being the most feared result. Moreover, surgical repair is associated with significant morbidity and mortality. We present a successful transapical percutaneous closure of a post‐surgical rapidly expanding left ventricular outflow tract (LVOT) pseudoaneurysm utilizing Amplatz Vascular Plug‐II (AVP‐II) (St. Jude Medical, St. Paul, MN) with the aid of 3D prototyping for pre‐procedural planning.     

Percutaneous Closure of a Left Ventricular Pseudoaneurysm in a High-Risk Surgical Candidate

Few cases of percutaneous device closure of a left ventricular pseudoaneurysm have been reported. We describe the case of a 67-year-old man with a history of coronary artery disease who presented with shortness of breath and chest pain. Computed tomographic angiography showed a left ventricular pseudoaneurysm that was filling from a small leak in the anterolateral aspect of the ventricle. The patient had undergone 3 previous sternotomies and was a high-risk candidate for surgical treatment of the pseudoaneurysm. Despite technical challenges, we closed the pseudoaneurysm percutaneously with use of a 6-mm AMPLATZER muscular ventricular septal defect occluder. The patient was released from the hospital the next day and was asymptomatic a year later.To our knowledge, this is the first report of the percutaneous closure of a left ventricular pseudoaneurysm via the femoral vein. We show that this manner of closure can be feasible in patients who have undergone multiple sternotomies and who are at high surgical risk.Key words: Aneurysm, false/complications/therapy; heart catheterization/instrumentation; heart ventricles; risk factors; septal occluder device; surgical procedures, minimally invasive; treatment outcome; ventricular dysfunction, left/complications/therapyA left ventricular (LV) pseudoaneurysm is a small channel that connects the LV to a large aneurysmal sac that contains blood and thrombus.¹ Complications of a pseudoaneurysm include rupture into the pericardium, peripheral embolization, and severe mitral regurgitation.² Emergent surgical repair is the preferred method of closing a pseudoaneurysm³; however, patients who have previously undergone cardiac surgery have a higher risk of morbidity and death after reoperation.^4,5 We describe the percutaneous closure of a pseudoaneurysm of the LV in a high-risk surgical candidate.     

Percutaneous device closure of a pseudoaneurysm of the left ventricular wall

The percutaneous device closure of a left ventricular pseudoaneurysm is described in a 60 year old man with a history of myocardial infarction complicated by ventricular tachycardia and left ventricular aneurysm treated by coronary artery bypass grafting and aneursymectomy with ventricular tachycardia ablation. He subsequently developed a vast pseudoaneurysm of the left ventricle with New York Heart Association functional class II heart failure symptoms. The selection of the approach and type of device used to close the neck of the pseudoaneurysm are discussed.     

Intracardiac echocardiography and fluoroscopy guided percutaneous left ventricular pseudoaneurysm closure

Left ventricular (LV) pseudoaneurysm is a rare complication after myocardial infarction and cardiac surgery. Standard treatment remains surgical correction; however, percutaneous closure has been attempted in high risk surgical patients. We report a case of three dimensional echocardiography and cardiac CT defined LV pseudoaneurysm which was closed percutaneously using intracardiac echocardiography (ICE) and fluoroscopy guidance. Appropriate planning and guidance proved essential to the procedure with an excellent outcome. Percutaneous closure of LV pseudoaneurysms is safe and feasible in high risk surgical patients and with appropriate imaging modalities may be an alternative to surgical correction. © 2011 Wiley Periodicals, Inc.     

Percutanous closure of left ventricular aneurysms in a patient with Loeys–Dietz syndrome

We report a case of percutaneous closure of multiple left ventricular aneurysms in a patient with inherited aortic‐aneurysm syndrome—the Loeys–Dietz syndrome. One aneurysm was a true aneurysm in the subaortic region and the second one was a pseudoaneurysm at the left ventricular apex. The patient was a high‐risk candidate for repeated operations. Both aneurysms were closed successfully percutaneously in staged procedures. There were no complications. The patient remained clinically well with stable echocardiographic results upon reassessment. This case illustrated that catheter‐based closure of left ventricular aneurysms is a feasible approach in the context of connective tissue abnormalities related to the Loeys–Dietz syndrome. © 2014 Wiley Periodicals, Inc.     

Left ventricular pulsus alternans in patients with hypertrophic cardiomyopathy and severe obstruction to left ventricular outflow

Left ventricular pulsus alternans (LVPA), a rhythmic beat to beat variation in left ventricular systolic pressure and outflow gradient, was noted in 35 of 200 ventricular systolic pressure and outflow gradient, was noted in 35 of 200 patients with hypertrophic cardiomyopathy undergoing hemodynamic study. LVPA was not associated with significant systemic pulsus alternans nor right ventricular pulsus alternans. All patients with LVPA had severe outflow gradients at rest or during provocation. Of 61 patients with severe basal outflow gradients (greater than 80 mm Hg), 12 demonstrated LVPA at rest. Eight of these patients underwent ventricular septal myotomy-myectomy; all had successful abolition of basal outflow gradient. Of the seven of these eight patients who underwent postoperative hemodynamic study and who were in sinus rhythm, none demonstrated LVPA. Eleven of 60 patients with basal outflow gradients ranging from 10 to 70 mm Hg demonstrated LVPA during maneuvers provocative for outflow gradients (mean gradient 90 +/- 37 mm Hg). Two of these patients underwent ventricular septal myotomy-myectomy; neither had a gradient nor LVPA during provocation postoperatively. Twelve additional patients with basal outflow gradients ranging from 0 to 115 mm Hg had LVPA after ectopic beats, generally occurring during maneuvers provocative for outflow gradients, associated with severe outflow gradients (mean gradient 130 +/- 39 mm Hg) during the postextrasystolic beat. None of the 41 patients without an outflow gradient, basal or during provocation, was found to have LVPA. Thus LVPA is commonly seen in during provocation, was found to have LVPA. Thus LVPA is commonly seen in patients with hypertrophic cardiomyopathy and severe left ventricular outflow gradients and may represent inadequate left ventricular contractile function in the presence of high left ventricular systolic pressures.     

Percutaneous closure of post TAVR LV apical pseudoaneurysm

Left ventricular (LV) apical pseudoaneurysm is a well known complication of myocardial infarction and open heart surgery procedures, and has more recently been described after transapical transcatheter aortic valve replacement (TAVR). Since the natural history includes a high incidence of cardiac rupture and mortality in the 30–45% range within the first year after diagnosis, surgical repair has been the main therapy. More recently, LV pseudoaneurysms have been closed using percutaneous methods. We describe a post‐TAVR pseudoaneurysm for which closure was done via retrograde LV access using a vascular plug, and provide a review of recent literature on closure methods and outcomes. © 2015 Wiley Periodicals, Inc.     

Successful embolization of a left ventricular pseudoaneurysm after perventricular ventricular septal defect device closure

Perventricular device closure has become an important management adjunct for ventricular septal defects deemed inoperable and difficult to address in the catheterization laboratory. Complications directly related to the procedure are rarely reported, and all have been manifest in the periprocedural period. We present the case of a 6‐week‐old boy who underwent perventricular closure of a muscular ventricular septal defect and had a left ventricle pseudoaneurysm identified 10 months later during catheterization to close residual septal defects. We describe the subsequent percutaneous coil embolization of the pseudoaneurysm and clinical follow‐up. © 2009 Wiley‐Liss, Inc.     

Percutaneous closure of left ventricle pseudoaneurysm using 3D printed heart model for procedure planning: A novel approach

Left ventricle pseudoaneurysm is a rare complication of myocardial infarction that carries a high risk of mortality. In this report, we present a case of successful percutaneous closure of left ventricle pseudoaneurysm using 3D printing for procedure guidance.     

Left ventricular basal inferior pseudoaneurysm and left atrial dissection after myocardial infarction: Case report

Left atrial dissection is a rare entity, mostly occurring after mitral valve surgery, with only a few cases described after myocardial infarction. The authors report a case of a 60‐year‐old man who presented with an inferior myocardial infarction, complicated with pseudoaneurysm of basal segment of left ventricular inferior wall, which expanded through the mitral ring to left atria, causing left atrial free wall dissection. The left ventriculo‐atrial communication through the pseudoaneurysm caused major para‐mitral regurgitation and the development of acute heart failure. Good clinical outcome was achieved with stabilization of acute heart failure with high‐dose diuretic therapy and delayed cardiac surgery with closure of left ventriculo‐atrial communication.     

Percutaneous closure of complex paravalvular aortic root pseudoaneurysm and aorta-cavitary fistulas

Native aortic valve or its prosthetic valve endocarditis can extend to the adjacent periannular areas and erode into nearby cardiac chambers, leading to pseudoaneurysm and aorta-cavitary fistulas respectively. The later usually leads to acute cardiac failure and hemodynamic instability requiring an urgent surgical intervention. However rarely this might pass unnoticed and the patient might present later with cardiac murmur. Percutaneous device closure of aortic pseudoaneurysm, ruptured sinus of Valsalva aneurysm, aorta-pulmonary window, paravalvular leaks, and aorta-cavitary fistula have been reported. We present a 59-year-old female who developed a large aortic root pseudoaneurysm with biventricular communication aorta-cavitary fistulas presenting late following aortic prosthetic valve endocarditis. She underwent successful percutaneous device closure of her pseudoaneurysm and aorta-cavitary fistulas using two Amplatzer Duct Occluders. This case illustrates a challenging combination of aortic root pseudoaneurysm and biventricular aorta-cavitary fistulas that was successfully treated with percutaneous procedure.     

Post myocardial infarction left ventricular pseudoaneurysm

Left ventricular pseudoaneurysm is a rare yet serious and challenging complication of myocardial infarction that requires a high index of suspicion as the clinical presentation is highly variable. We present a case of post infarction thrombosed left ventricular pseudoaneurysm in a patient who presented with non-specific complaints months after the initial cardiac injury. Multimodality imaging helped in characterizing the pseudoaneurysm and planning for definite therapy.     

Percutaneous Closure of a Giant Aortic Pseudoaneurysm Using Multimodality Imaging Guidance

Ascending aortic pseudoaneurysm is a rare, life-threatening complication of cardiac surgery. Surgical management is recommended, however, transcatheter techniques offer a less invasive alternative. We describe successful percutaneous closure, guided by using multimodality imaging, in a patient with high surgical risk.     

Coronary Artery Pseudoaneurysm: Closure With Pericardium-Covered Stents,Guided by Cardiac Computed Tomography Angiography

Coronary aneurysms are found in approximately 5% of patients undergoing coronary angiography. We describe a case of a coronary artery pseudoaneurysm. The use of cardiac computed tomography angiography is demonstrated in the planning and follow-up of a percutaneous closure of the pseudoaneurysm with pericardium-covered stents.     

Percutaneous closure of ascending aortic pseudoaneurysm using Amplatzer septal occluder device: the first clinical case report and literature review.

We report the first case of the use of an Amplatzer septal occluder device to close a large ascending aortic pseudoaneurysm. The patient had a complex cardiac history with redo coronary artery bypass graft surgery, severe left ventricular dysfunction, and end-stage renal disease requiring hemodialysis. The procedure was successfully performed under fluoroscopic and 2D/3D transthoracic echocardiographic guidance. Six-week follow-up with both transthoracic echocardiography and MRI showed the device was in proper position with complete closure of the pseudoaneurysm.     

A giant left ventricular pseudoaneurysm as a late sequela of aortic valve endocarditis

Left ventricular pseudoaneurysm is an uncommon complication of infective endocarditis, usually presenting within several weeks of the infective episode. We describe a 37-year-old man who presented with exertional dyspnea nearly a year after a prolonged hospitalization for lung abscess. Imaging studies showed new aortic valve regurgitation and a giant pseudoaneurysm extending inferoposteriorly from the left ventricle. At thoracotomy, a perforated aortic valve was found, suggesting a healed endocarditis. The patient underwent successful aneurysmectomy and patch closure with aortic valve repair. This case underscores the potential for very late nonvalvular cardiac complications of infective endocarditis and is also distinctive because of the large size of the pseudoaneurysm.     

An arrhythmic storm: a potential complication on opening the umbrella for percutaneous closure of interatrial communications

Interatrial communications (ICs) have been linked to paradoxic embolism, which may be prevented using both surgical and percutaneous interventions. The case of a 61-year-old woman with a history of transient cerebral ischemic attack who developed repetitive ventricular arrhythmias and an intermittent left branch bundle block immediately after percutaneous closure of an IC is described. Transthoracic echocardiography showed that the device had migrated into the left ventricular outflow tract, and the patient consequently underwent emergency cardiac surgery to retrieve the device and repair the IC. In conclusion, percutaneous transcatheter closure of ICs is more rapid and less invasive compared with surgery, but nevertheless may be associated with significant short-term morbidity.