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Percutaneous closure of a large peri-prosthetic left ventricular pseudoaneurysm in a high-risk surgical candidate

B K Dundon, R A S Yeend, S G Worthley

Correspondence to:
benjamin.dundon{at}adelaide.edu.au

A 71-year-old woman presented with increasingly severe congestive cardiac failure 6 months after dual aortic/mitral bioprosthetic valve replacement for severe rheumatic valvular heart disease. Echocardiography showed the presence of a large (7.6x3.6x7.0 cm) left ventricular pseudoaneurysm (LVPA) originating from a 1.1 cm lateral free-wall disruption adjacent to the mitral prosthesis (fig 1, panels A and C). Given the risk of rupture and sudden death, urgent surgical repair was sought; however, procedural risk was deemed prohibitive owing to patient comorbidities. A novel percutaneous approach was considered.

Multidetector computed tomography demonstrated the feasibility of LVPA closure via a retrograde approach (video 1). Percutaneous closure was undertaken via femoral arterial access, using fluoroscopic and combined transoesophageal/transthoracic echocardiographic guidance. Once across the bioprosthetic aortic valve, a 9F-delivery catheter was passed "behind" the mitral prosthetic support struts and into the LVPA cavity. A 12 mm Amplatzer ventricular–septal occluder (AGA Medical Corporation, Golden Valley, Mn, USA) was delivered successfully, with short postprocedural hospitalisation and marked improvement in heart failure symptoms (fig 1, panels B and D; video 2).

Mitral valve replacement is associated with significant morbidity and mortality, and late complications such as valve dehiscence and pseudoaneurysm are not uncommon. Although published series have confirmed the utility of percutaneous closure for paravalvular dehiscence,¹ perivalvular free-wall rupture and LVPA formation has routinely required repeat surgery, with high mortality rates.² Isolated cases of percutaneous LVPA closure have been reported previously; however, the technical complexity of periprosthetic LVPA has previously prevented such an approach. As far as we are aware, this is the first published report of successful closure of a large, periprosthetic LVPA in a high-risk surgical candidate.

View this figure (48K): in this window | in a new window | PowerPoint for Teaching   Figure 1 Angiographic (A, B) and computed tomography multiplanar reconstructions (C, D) demonstrating the large, posterolateral left ventricular pseudoaneurysm (arrowheads) originating from a free-wall disruption adjacent to the mitral bioprosthesis (MV). In the postprocedural panels (B, D), the closure device is indicated (arrow), sited behind the supporting struts of the mitral prosthesis.

 

This article has been adapted from Dundon B K, Yeend R A S, Worthley S G. Percutaneous closure of a large peri-prosthetic left ventricular pseudoaneurysm in a high-risk surgical candidate Heart 2008;94:1043

Competing interests: None.

Patient consent: Informed patient consent was obtained for publication of the case details described in this report.

Additional videos are published online only at http://heart.bmj.com/content/vol94/issue8

1. Pate, GE, Al Zubaidi, A, Chandavimol, M, et al. Percutaneous closure of prosthetic paravalvular leaks: case series and review. Catheter Cardiovasc Interv 2006;68:528–33.[CrossRef][Medline]
2. Frances, C, Romero, A, & Grady, D. Left ventricular pseudoaneurysm. J Am Coll Cardiol 1998;32:557–61.[Abstract/Free Full Text]

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