Ann Thorac Surg 2008;85:634-636. doi:10.1016/j.athoracsur.2007.08.042
© 2008 The Society of Thoracic Surgeons
Case Reports
Percutaneous Closure of Left Ventricular Pseudoaneurysms After Ross Procedure
Huda Elshershari, MD,
Jeffrey G. Gossett, MD*,
Ziyad M. Hijazi, MD
Department of Pediatric Cardiology, University of Chicago, Chicago, Illinois
Accepted for publication August 21, 2007.
* Address correspondence to Dr Gossett, Division of Pediatric Cardiology, Children’s Memorial Hospital, 2300 Children’s Plaza, Box 21, Chicago, IL 60614 (Email: jgossett{at}childrensmemorial.org).
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Abstract
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Pseudoaneurysm formation is a dangerous, but uncommon, complication after the Ross procedure. We describe a patient in whom two pseudoaneurysms formed at the proximal suture line of the pulmonary autograft. These were successfully treated percutaneously, one by placement of an Amplatzer Septal Occluder (AGA Medical, Golden Valley, MN), and the other with coil embolization.
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Introduction
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The use of pulmonary autografts for aortic valve replacement (the Ross procedure) has gained a role as treatment for aortic valve disease [1–4]. Pseudoaneurysm (PA) formation in the left ventricular outflow tract (LVOT) related to the proximal end of the pulmonary autograft has been reported [5–7]. The PAs were repaired surgically in these cases.
We report a patient in whom two PAs formed after the Ross procedure. These were treated percutaneously using an Amplatzer Septal Occluder (ASO) (AGA Medical, Golden Valley, MN) and Flipper coil embolization (Cook Medical, Bloomington, IN).
A 13-year-old boy with anomalous origin of the left coronary artery from the right sinus of Valsalva with an intramural course underwent an unroofing procedure. Immediately after the procedure he was found to have hemodynamically significant aortic valve regurgitation and after 6 months of medical therapy he underwent a Ross procedure. His postoperative course was uneventful. A few weeks later, routine echocardiogram showed a PA from the LVOT below the aortic valve. Follow-up weekly echocardiograms were performed and 2 weeks later revealed that the PA had grown in size to measure at least 2 x 5.6 x 4.4 cm.
Given his high surgical risk he was referred for percutaneous management. He was taken to the cardiac catheterization laboratory where a transesophageal echocardiogram confirmed the anatomy with the origin of the large PA posterior and rightward in the LVOT (Fig 1A). Angiography documented the presence of two PAs: one large PA extending from the posterior aspect of the LVOT just below the aortic valve and a second small PA from the leftward aspect of the LVOT (Fig 1B). The large PA was entered with a Judkin left (JL) coronary catheter (Fig 1C). The Judkin left catheter was exchanged for a Judkin left guide catheter and a 5-mm ASO device was placed across the mouth of the aneurysm under fluoroscopic and transesophageal echocardiographic guidance (Fig 1D). Angiography and transesophageal echocardiography revealed occlusion of the PA opening with clot formation seen by echocardiography (Fig 1E, 1F). There was no evidence of compromise of the aortic root and aortic or mitral valves. Attempts at entry into the second small PA were unsuccessful and were therefore abandoned.
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Fig 1. (A, B) A large pseudoaneurysm (PA) (arrows) is seen arising posterior and rightward from the left ventricular outflow tract. Angiography confirms the presence of an additional smaller leftward aneurysm. (C) The large PA is entered with the catheter. (D) A 5-mm Amplatzer atrial septal defect occluder (AGA Medical, Golden Valley, MN) (arrow) is deployed in the mouth of the PA. (E) Angiography shows the device to be appropriately seated with foaming of contrast through the device. (F) Spontaneous contrast is seen by a transesophageal echocardiographic scan within the PA consistent with clotting of the PA.
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One month later, echocardiogram confirmed device closure of the PA. However, the second PA had grown in size. The patient returned to the catheterization laboratory where angiography showed no flow into the previously occluded PA (Fig 2A). The smaller aneurysm had grown significantly, extending leftward and anteriorly from the LVOT (Figs 2A–2C). The PA was engaged with a Judkin left catheter (Fig 2D). Attempts to place a 4-mm ASO in the mouth of the PA were unsuccessful. An 8 mm x 10 cm Flipper coil (Cook Medical) was deployed inside the PA. Two 5 mm x 8 cm Flipper coils were then placed in the mouth of the PA. Complete closure of the PA was documented by angiography and transesophageal echocardiography scans (Figs 2E, 2F). An ascending aortic angiogram revealed no aortic regurgitation and unobstructed coronary artery flow. Follow-up visits and echocardiograms for 3 months post-procedure confirmed complete occlusion with no untoward effect.
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Fig 2. Angiography in the left ventricular outflow tract documents no flow across the previously placed Amplatzer atrial septal defect occluder (AGA Medical, Golden Valley, MN). (A–C) The smaller pseudoaneurysm (PA) (arrows) is seen to have significantly grown in size. (D) This PA is entered with the catheter (arrow). (E, F) After coil placement complete occlusion of both PAs is confirmed by transesophageal echocardiography and angiography (arrows).
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Comment
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Pseudoaneurysm formation is a serious and uncommon complication after the Ross procedure. Metras and colleagues [5] reported an 8-year-old child with a PA arising at the proximal suture line of the pulmonary autograft who presented with pulmonary artery hypertension, as well as aortic and mitral insufficiency. The patient underwent emergent reoperation, but died on the first postoperative day. Shahid and colleagues [6] reported PA formation in the LVOT related to the proximal end of the pulmonary autograft in one case and true aneurysm in another. Both of these occurred late after operation and were surgically repaired without complications. The causes of PA formation are postulated to include infection, failure to capture all layers of the aorta with the suture, tension on the suture line, compliance mismatch, and suture pulling through a diseased aortic wall [5]. One hypothesis is that infundibular muscle attached to the proximal end of the autograft may dilate when exposed to systemic pressure [6]. Attention postoperatively with echocardiography is required for early detection of PA and early intervention.
As reoperation for excision of PA carries substantial risks [5], percutaneous management may represent an acceptable alternative strategy. Use of an ASO has recently been described for closure of a PA from the pulmonary artery in a pediatric patient [8]. Benefits of percutaneous management include the relative ease of use of the devices such as the ASO or coils, or both, and the avoidance of surgical morbidity. Although no complications occurred during our case, potential pitfalls include improper measurement of the orifice of the PA and the potential for perforation of the PA with catheter or wire manipulation. Patient selection most likely should exclude those with an infected PA. Although we achieved early success in our patient, long-term follow-up is necessary to prove that percutaneous management provides durable outcomes.
In conclusion, pseudoaneurysm formation after the Ross procedure is a rare but serious complication. Follow-up with echocardiography is indicated to monitor for the occurrence of PA and to allow for prompt intervention. Transcatheter device closure of one PA and coil embolization of another PA was safe and effective in our hands. Long-term follow-up will be needed to document durability of our results.
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Acknowledgments
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We would like to thank Drs Peter Koenig, David Bichell, and Qi-Ling Cao for their assistance.
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References
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- Kouchoukos NT, Masetti P, Nickerson NJ, et al. The Ross procedure: long-term clinical and echocardiographic follow-up Ann Thorac Surg 2004;78:773-781.[Abstract/Free Full Text]
- Sievers H, Dahmen G, Graf B, et al. Midterm results of the Ross procedure preserving the patient’s aortic root Circulation 2003;108(Suppl 1):II55-II60.[Medline]
- Luciani GB, Favaro A, Casali G, et al. The Ross operation in the young: a 10-year experience Ann Thorac Surg 2005;80:2271-2277.[Abstract/Free Full Text]
- Chambers JC, Somerville J, Stone S, Ross DN. Pulmonary autograft procedure for aortic valve diseaseLong-term results of the pioneer series. Circulation 1997;96:2206-2214.[Abstract/Free Full Text]
- Metras D, Kreitmann B, Habib G, Riberi A, Yao JG, Ross DN. False aneurysm: a rare and potentially severe complication after pulmonary autograft operation J Heart Valve Dis 1996;5:414-417.[Medline]
- Shahid MS, Al-Halees Z, Khan SM, Pieters FA. Aneurysms complicating pulmonary autograft procedure for aortic valve replacement Ann Thorac Surg 1999;68:1842-1843.[Abstract/Free Full Text]
- Pasquali SK, Cohen MS, Shera D, Wernovsky G, Spary TL, Marino BS. The relationship between neo-aortic root dilation, insufficiency and reintervention following the Ross procedure in infants, children and young adults J Am Coll Cardiol 2007;49:1806-1812.[Abstract/Free Full Text]
- Vaidyanathan B, Kannan B, Kumar RK. Catheter closure of pseudoaneurysm of the main pulmonary artery Circulation 2004;110:e322-e323.[Free Full Text]
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Ann. Thorac. Surg.,
October 1, 2009;
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e31 - e33.
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Abstract
Introduction
