Hybrid Repair of Left Ventricle Pseudoaneurysm Utilizing a Transapical and Transseptal Approach
Presenter
Ahmad Al Turk, Banner - The University of Arizona, Phoenix, AZ
Ahmad Al Turk, Banner - The University of Arizona, Phoenix, AZ
Keywords: TEER/TMVR/Mitral Valve
Background
We present a case of an enlarging LV pseudoaneurysm complicating mitral valve endocarditis, the patient was at increased surgical risk and underwent a hybrid repair utilizing a transapical and transeptal approach.
Methods
45-year-old man developed mitral valve endocarditis complicated by a large abscess near the posterior mitral annulus extending into the atrioventricular groove. He was treated with intravenous antibiotics therapy initially without planned surgery given his elevated surgical risk. Antibiotics were effective, however; the patient developed symptomatic mitral valve regurgitation and red blood cell (RBC) hemolysis. Transesophageal echocardiography (TEE) confirmed an aneurysmal cavity in the peri-mitral area. Color Doppler investigation showed flow proceeding from the LV entrance into the cavity and out the windsock aneurysm perforation into the left atrium (LA). The regurgitation was qualified as moderate to severe. Computed tomography scan was then utilized for procedural planning.
Results
Patient was treated with trans-apical aneurysm repair. After obtaining LV apical access, the aneurysm and the LV to LA tract were wired. The aneurysm was then packed with Penumbra coils while the LV to LA tract was closed using an Amplatz muscular ventricle septal defect occluder. (9-VSD-MUSC-008). This resulted in significant regurgitation reduction. The neck of the pseudoaneurysm on the LA side had residual flow and could not be obliterated. The patient continued to have RBC hemolysis; hence he was further treated using a transseptal approach. The aneurysm neck was accessed from the left atrial side by electrifying an Astato wire under TEE guidance, additional coils were deployed obliterating the pseudoaneurysm neck and further decreasing the regurgitation. The patient's symptoms and red blood cell hemolysis improved, and the patient was discharged with a stable hemoglobin.
Conclusions
When surgical repair is not a treatment option for an enlarging LV pseudoaneurysm, less invasive measures should be attempted. Completely obliterating the flow in the pseudoaneurysm appears to be key for success. This may require a hybrid transapical and transseptal approach as in the case presented.