Ann Thorac Surg 2009;88:e31-e33. doi:10.1016/j.athoracsur.2009.07.032
© 2009 The Society of Thoracic Surgeons
Case Reports
Percutaneous Device Closure of Iatrogenic Left Ventricular Wall Pseudoaneurysm
Gabriele Vignati, MD,
Giuseppe Bruschi, MD*,
Luigi Mauri, MD,
Giuseppe Annoni, MD,
Maria Frigerio, MD,
Luigi Martinelli, MD,
Silvio Klugmann, MD
A De Gasperis Cardiology & Cardiac Surgery Department, Niguarda Ca' Granda Hospital, Milan, Italy
Accepted for publication July 2, 2009.
* Address correspondence to Dr Bruschi, A De Gasperis Cardiology & Cardiac Surgery Department, Niguarda Ca' Granda Hospital, Piazza Ospedale Maggiore, 3, Milan, 20162, Italy (Email: giuseppe.bruschi{at}fastwebnet.it).
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Abstract
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A 67-year-old man with ischemic cardiomyopathy was transferred to our hospital in cardiogenic. During a video-assisted mini-thoracotomy for left ventricular epicardial lead implantation, a left ventricular free-wall rupture occurred and an emergency surgical repair was performed. Postoperatively patients experience left ventricular wall pseudoaneurysm. After stabilization of clinical conditions with aggressive medical treatment, we decided to attempt a minimally invasive procedure (ie, a transcatheter pseudoaneurysm closure). To date, few cases of device closure of left ventricle pseudoaneurysm are reported in the literature, usually secondary to myocardial infarction, and we believe this is the first case of left ventricle pseudoaneurysm after iatrogenic left ventricle laceration and surgical closure.
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Introduction
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The estimated overall incidence of cardiac perforation from catheter-based procedures is less than 1% [1]. Surgery should be needed, and we report a case of left ventricular wall pseudoaneurysm after surgical repair of iatrogenic left ventricle laceration, successfully performed by transcatheter closure using an Amplatzer septal occluder (AGA Medical Corp, Golden Valley, MN).
A 67-year-old man with ischemic cardiomyopathy was transferred to our hospital in cardiogenic shock on November 2008. In 1989, the patient had undergone coronary artery bypass grafting for acute myocardial infarction and three different percutaneous coronary interventions in 1999, 2004, and 2005. Due to heart failure, associated with left bundle branch block, cardiac resynchronization therapy was attempted at another hospital in October 2008. A percutaneous coronary sinus approach failed, and the patient underwent a video-assisted, mini-thoracotomy, left ventricular epicardial lead implantation. This procedure was complicated by left ventricle free-wall rupture that required emergency surgical repair with a pericardial patch placement. The patient's postoperative course was characterized by low cardiac output syndrome. On postoperative day 15, an echocardiogram revealed severe left ventricular (LV) dysfunction with an ejection fraction of 20% and presence of a huge LV wall pseudoaneurysm (internal end-systolic dimension of 35 x 55 mm), with a high-velocity jet between LV inferolateral wall and a pseudoaneurysm through a 5-mm diameter orifice.
After stabilization of clinical conditions with aggressive medical treatment, and considering patient history and status, aneurysm size, position, and orifice, different treatments have been evaluated from a standard surgical approach to heart transplantation, but we decided to attempt a minimally invasive procedure (ie, a transcatheter pseudoaneurysm closure).
Cardiac catheterization and LV angiogram were performed, demonstrating a large (60 x 70 mm) pseudoaneurysm, with contrast flow through a narrow neck into the large blind sac (Fig 1). Residual perforation of left free wall was nearest to the epicardial lead previously implanted. Closure of the defect was then successfully undertaken with the patient under mild sedation using fluoroscopy guidance. An 8F delivery sheath was advanced retrogradely from the left femoral artery into the left ventricle and then into the pseudoaneurysm. A 5-mm Amplatzer septal occluder (AGA Medical Corp) was than deployed, occluding the perforation. A subsequent angiogram showed the defect to be successfully occluded with only a trivial residual leak related to the interference of the epicardial lead, with the external disc of the Amplatzer device (Fig 2). The leak had completely sealed as shown on echocardiography and a computed tomographic scan at discharge on post-procedure day 14. The patient was in New York Heart Association functional class IIb at 4-months follow-up with echocardiographic evidence of complete closure.
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Fig 1. Angiographic view demonstrates a large (60 x 70 mm) pseudoaneurysm with contrast flow through a narrow neck into the large blind sac. Note the epicardial lead previously implanted nearest to left ventricular perforation site.
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Fig 2. The 5-mm Amplatzer septal occluder (AGA Medical Corp, Golden Valley, MN) in situ at the neck of the left ventricular pseudoaneurysm, only a trivial residual leak related to the interference of epicardial leads with the external disc of the device being evident.
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Comment
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A catastrophic complication that may result from implantation of electrodes in cardiac resynchronization therapy is ventricular laceration. The incidence of this complication has been reported to be 0.5% to 1% [1]. In the clinical setting, the acute free-wall perforation is commonly recognized after hemodynamic deterioration due to tamponade, and it requires immediate surgical intervention. A rare complication after surgery should be a left ventricular pseudoaneurysm (LVPA) pathologically. A pseudoaneurysm of the left ventricle is characterized by a small, narrow-necked channel that connects the ventricle with a larger aneurysmal sac, which contains blood and thrombus and is lined by fibrous pericardial tissue with no myocardial elements, and which also generally occurs when cardiac rupture in the myocardium is contained by adherent pericardium or scar tissue. Previous cardiac surgery accounts for a third of cases of LVPA, and mitral valve replacement is the most common antecedent surgical procedure [2]. In these cases, post-surgical adherent tissue may contain the rupture and prevent tamponade.
The largest series of 290 patients reported by Frances and colleagues [2] identified myocardial infarction as the most common cause of LVPA, and the authors found that inferior myocardial infarction accounts for approximately twice as many cases as anterior myocardial infarctions. Trauma, infection, and previous cardiac catheterization have also been implicated.
Conventional treatment for LVPA is surgical repair, because untreated pseudoaneurysms have an approximately 30% to 45% risk of rupture in the first year. Nevertheless, surgical repair has a reported mortality of less than 20% [2].
Recently the implementation of rapidly evolving and expanding catheter-based technologies has provided an alternative option in a cohort of patients at high-operative risk with suitable anatomical characteristics. Only a few experiences with percutaneous device closure have been reported in the literature regarding percutaneous closure of the LVPA in patients who were deemed high risk for surgery. In 2004, Clift and colleagues [3] first reported the case of a 60-year-old man who sustained a myocardial infarction complicated by an LV aneurysm. The patient was operated on for coronary artery bypass grafting, and an LV aneurysmectomy was experienced 2 years after surgery, with a large pseudoaneurysm of the posterior LV wall. Through a brachial approach, a 12-mm Amplatzer septal occluder was placed across the neck of the false aneurysm. Gladding and colleagues [4] described percutaneous closure of a LV free-wall rupture site with associated false aneurysm in an 86-year-old woman who had suffered prior inferolateral myocardial infarction. Transcatheter closure of the false aneurysm was successfully undertaken by a 12-mm Amplatzer septal occluder deployed retrogradely from the right femoral artery through a bioprosthetic aortic valve. Graham and colleagues [5] reported the case of a 40-year-old woman who underwent multiple redo surgical operation after homograft aortic valve replacement. She had a false aneurysm develop of the left ventricular outflow tract that was successfully occluded with a 4-mm Amplatzer muscular ventricular septal defect device. Harrison and colleagues [6] reported a successful percutaneous LVPA closure, post-inferior MI, in a 47-year-old woman using an 18-mm Amplatzer muscular ventricular septal defect occluder. The primary aim of the treatment was to prevent recurrent embolic stroke. Dundon and colleagues [7] reported a successful closure of a large, peri-prosthetic LVPA in a 71-year-old woman 6 months after an aortic-mitral bioprosthetic valve replacement. Elshershari and colleagues [8] described a successful percutaneous combined Amplatzer septal occluder and coil embolization treatment of two LVPAs at the proximal suture line of the pulmonary autograft in a 13-year-old boy. We should note that our case had multiple unique characteristics; not only the presence of the epicardial leads that could interfere with the external disc of the Amplatzer device, but also clinical conditions of the patient. A 67-year-old man with previous coronary artery bypass grafting for acute myocardial infarction and no viable myocardium, without indication to further surgical revascularization, had bedridden inotropes, dependent with LV ejection fraction of 20%. The expected goal of our procedure was the stabilization of the clinical conditions of the patient with a simple, noninvasive percutaneous procedure. Literature review emphasizes the role that percutaneous closure devices should have in treating patients with LVPA. In all reported experiences transcatheter closure was safe and effective; this procedure offers a viable alternative to surgical repair in selected high-risk surgical candidates.
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References
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- Ward DE, Camm AJ. Clinical electrophysiology of the heartLondon, United Kingdom: E. Arnold; 198717.
- Frances C, Romero A, Grady D. Left ventricular pseudoaneurysm JACC 1998;32:557-561.[Abstract/Free Full Text]
- Clift P, Thorne S, de Giovanni J. Percutaneous device closure of a pseudoaneurysm of the left ventricular wall Heart 2004;90:e62-e63.[Abstract/Free Full Text]
- Gladding PA, Ruygrok PN, Greaves SC, Gerber IL, Hamer AW. Percutaneous closure of a left ventricular free-wall rupture site Circulation 2006;113:e748-e749.[Free Full Text]
- Graham EM, Bandisode VM, Atz AM, Kline CH, Taylor MH, Ikonomidis JS. Percutaneous occlusion of a pseudoaneurysm evolving after homograft aortic valve and root replacement with the Amplatzer muscular ventricular septal defect occluder J Thorac Cardiovasc Surg 2006;131:914-916.[Free Full Text]
- Harrison WH, Ruygrok PN, Greaves S, et al. Percutaneous closure of left ventricular freewall rupture with associated false aneurysm to prevent cardioembolic stroke Heart, Lung and Circulation 2008;17:243-263.
- Dundon BK, Yeend RAS, Worthley SG. Percutaneous closure of a large periprosthetic left ventricular pseudoaneurysm in a high-risk surgical candidate Heart 2008;94:1043.[Free Full Text]
- Elshershari H, Gossett JG, Hijazi ZM. Percutaneous closure of left ventricular pseudoaneurysms after Ross procedure Ann Thorac Surg 2008;85:634-636.[Abstract/Free Full Text]
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Abstract
Introduction
