Title
Double Trouble: A Case Presentation of Endovascular Repair of Simultaneous LVOT Pseudoanuerysm and Mitral Valve Paravalvular Leak
Introduction
This case presentation will highlight the complex decision making required to formulate a treatment plan for a patient presenting in acute heart failure found to have an expanding LVOT pseudoanuerysm and mitral valve paravalvular leak. Furthermore, the technical details of a hybrid approach will be reviewed.
Clinical Case
A 60 year-old-male with past medical history of coarctation repair, bicuspid aortic valve c/b endocarditis s/p mechanical 25 mm St. Jude aortic valve and 29 mm St. Jude mitral valve replacements in 1988 on warfarin, atrial fibrillation, HFrEF (EF 40%), and HLD presented to our outpatient clinic from an outside institution. The patient had a known LVOT pseudoaneurysm that was stable in 2010 (4.0 x 2.3 x 3.0 cm), and surveillance was recommended. He was lost to follow-up until 2017 when he had a CTA for his history of coarctation and the pseudoaneurysm was noted to be 4.3 x 2.9 x 3.6 cm in size. Surveillance continued over the next 5 years. In January 2022, he presented with slightly worsening HF symptoms (NYHA II) and a repeat CTA demonstrating the pseudoaneurysm had increased from 4.4 X 2.6 X 3.5 cm to 5.5 X 5.6 X 4.8 cm in two years and communicated with an aortic paravalvular leak. Additionally, the CTA noted an anterior paravalvular leak of the mitral mechanical valve with at least moderate regurgitation. Following a HEART team discussion, the decision was made to proceed with a hybrid approach for repair due to the high morbidity associated with redo sternotomy. Thus, the patient underwent a mini-thoracotomy with trans-apical access using a 6Fr sheath. A 10 mm AVP2 vascular plug was delivered to the LVOT pseudoaneurysm, and an 8mm AVP2 vascular plug was delivered across the mitral paravalvular leak. Follow-up imaging demonstrated obliteration of the pseudoaneurysm and no residual paravalvular leak with an improved EF of 60%.
Discussion
Following an extensive multidisciplinary discussion, the hybrid approach was chosen due to his anatomy and the angles required to successfully wire each valvular issue. Pre-procedural planning, including analysis of previous CTA studies as well as the pre-procedural TEE, was paramount for procedural success as well as knowledge of available devices and their compatibility with equipment. Finally, the team required for this procedure consisted of structural interventional cardiology, adult congenital interventional cardiology, and cardiothoracic surgery. These procedures require extensive discussion and collaboration amongst a breadth of experts in order to achieve procedural success.