Title:
LV Pseudoaneurysm Closure: Planning the Approach
Introduction:
Left ventricular(LV) pseudoaneurysms are a rare complication following aortic root replacement surgery. When evaluating approaches for percutaneous closure of the pseudoaneurysms, it is important to use advanced cardiac imaging for planning.
Clinical Case:
59 y/o man with history of obstructive sleep apnea, tobacco abuse, and thoracic aortic aneurysm who had a valve sparing aortic root replacement (David Procedure) three months prior presented after a routine follow up computerized tomography (CT) scan found a large perigraft hematoma with evidence of active contrast extravasation into the hematoma with a 1.6 mm neck from the left ventricle.
Cardiac CT and LV angiography confirmed the neck of the pseudoaneurysm to arise beneath the commissure of the non and right coronary cusps.
The patient was brought to the catherization lab for percutaneous closure of the pseudoaneurysm using a transfemoral approach with retrograde crossing of the aortic valve.
An 8F sheath was placed in the right common femoral artery.
Using transesophageal echocardiography (TEE) including EchoNav (Philips Medical Systems) and fluoroscopic guidance, multiple catheters (including a deflectable guide catheter) and different techniques (including telescoping catheters)were used to engage the neck of the pseudoaneurysm. The pseudoaneurysm could be engaged with a wire, but we were unable to deliver a microcatheter to exchange for a stiffer wire to deliver a vascular plug due to marked angulation. Given the length of the procedure and the proximity of the neck to the aortic valve annulus and leaflets, the decision was made to stop the procedure and plan for a transapical approach.
The patient returned to the operating room 48 hours later, after a multi-disciplinary team meeting and further planning. CT-Surgery performed an 8 cm left anterolateral thoracotomy and a pericardiotomy exposing the LV apex.
Multiple stay sutures were placed above and below the pericardium. A micropuncture needle and wire accessed the LV apex, followed by insertion of
a 7 Fr x 23 cm sheath.
A Kumpe diagnostic catheter and an angled glidewire was advanced into the pseudoaneurysm.
The Kumpe catheter was advanced and the glidewire was exchanged for an Amplatz wire. The Kumpe catheter was removed. The BriteTip sheath was advanced into the pseudoaneurysm. A 6 mm Amplatz Vascular Plug II was deployed in the neck and the sheath was pulled basck into the LV.
Repeat angiography found trivial residual flow in the PSA.
The sheath was removed and purse string sutures were used to close the LV apex. Repeat CT found complete closure of pseudoaneurysm neck with mild decrease in size of the hematoma. The patient was discharged from the hospital on post operative day four without complication.
Discussion:
Reviewing the Cardiac CT and LV angiography, the retrograde approach across the aortic valve to close the pseudoaneurysm was more difficult due to the proximity to the annulus and the aortic valve leaflets. A hybrid transapical approach may allow a more coaxial direct approach based on angulation of the PSA neck with less risk than a redo sternotomy.