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J Thorac Cardiovasc Surg 2006;131:914-916
© 2006 The American Association for Thoracic Surgery
Brief Communication |
a Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, SC.
b Division of Cardiology, Medical University of South Carolina, Charleston, SC.
c Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC.
Received for publication November 8, 2005; accepted for publication November 15, 2005. * Address for reprints: Varsha M. Bandisode, MD, Medical University of South Carolina, 165 Ashley Ave, PO Box 250915, Charleston, SC 29425. (Email: bandisvm{at}musc.edu).
Aortic root replacement with aortic homograft has yielded good results in appropriate patients. Aortic pseudoaneurysms are a rare postoperative complication, potentially leading to reoperation with significantly higher surgical mortality.
1
We describe a case in which a left ventricular outflow tract pseudoaneurysm is successfully occluded with transcatheter device closure in a patient at high risk for reoperation.
Clinical Summary
A 40-year-old woman presented with a history of a bicuspid aortic valve with severe insufficiency, ascending aortic aneurysm, and hemiarch aneurysm. After discussion of the various treatment options, she underwent surgical replacement with a 22-mm homograft aortic valve, root, and ascending aorta. Her midterm postoperative course was complicated by gram-negative endocarditis and dehiscence of the homograft. Her aortic homograft was rereplaced 22 days after initial intervention and was complicated by uncontrollable bleeding from a posterior annular suture line. An anterior pericardial baffle was created and decompressed to the right atrial appendage, resulting in hemostasis. At 48 days after the second surgical intervention, follow-up revealed a persistent and increasing left-to-right shunt. At surgical re-exploration, an unsuccessful attempt (caused by continued bleeding) was made to repair the homograft at the posterior annulus, requiring replacement of the pericardial baffle.
Serial computed tomographic angiography revealed closure of the left-to-right shunt, but a contained pseudoaneurysm remained in the lateral aspect of the left ventricular outflow tract directed posteriorly between the left atrium and the aortic arch and draped by the left main coronary artery. Serial evaluations revealed progressive enlargement of the pseudoaneurysm with tenting of the left main coronary artery at its bifurcation.
Given her multiple reoperations, she was referred for transcatheter device occlusion of the pseudoaneurysm. Institutional review board approval for compassionate use of the device, as well as informed consent, was obtained. Transthoracic echocardiography revealed a 3.5 x 1.6–cm pseudoaneurysm located posteriorly and leftward of the aortic valve. The neck to the pseudoaneurysm originated under the aortic valve within the left ventricular outflow tract. The distance between the homograft aortic valve, the anterior mitral leaflet hinge point, and the neck of the pseudoaneurysm was 6 and 7 mm, respectively.
A right and left heart catheterization was performed by using the right femoral vein and artery, respectively with selective angiography of the left ventricle, aortic root and coronary arteries. A 5F 100-cm JR 3.5 catheter (Cook, Bloomington, Ind) was advanced retrogradely from the femoral artery into the left ventricle, and the pseudoaneurysm was engaged. Angiography of the pseudoaneurysm revealed the neck measured 3.5 mm in diameter, with tenting of the left main coronary artery (Figure 1). Standard device delivery sheaths provided inadequate length for stable sheath placement and device deployment. An 8F SL2 transseptal sheath (St Jude Medical, Inc, Minnetonka, Minn) was loaded with a 7F IB catheter (Boston Scientific, Natick, Mass), with stable position in the pseudoaneurysm. A 4-mm Amplatzer muscular ventricular septal defect occluder device (AGA Medical, Golden Valley, Minn) was placed in the neck of the pseudoaneurysm with transesophageal echocardiographic guidance. The distal disk was deployed in the aneurysm, and the device waist was deployed in the aneurismal neck. The proximal disk was deployed on the ventricular aspect of the subvalvar aortic root. Obliteration of blood flow into the pseudoaneurysm was noted by means of echocardiography and angiography (Figure 2). No change in aortic or mitral valve function was observed. The postprocedure recovery was uneventful, with extubation in the catheterization laboratory, an overnight observation, and subsequent discharge the following morning without complications. Transthoracic echocardiography and computed tomographic angiographic studies performed 1 month after the procedure confirmed complete occlusion of the pseudoaneurysm with resolving hematoma, no change in aortic or mitral valve function, and no residual tenting of the left coronary artery.
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Pseudoaneurysm formation after aortic root replacement is a postoperative complication that has traditionally been addressed by surgical means. Reoperation increases both the difficulty for exposure of the surgical field caused by scar tissue and surgical mortality.
Reports of percutaneous occlusion of aortic aneurysms have been described by using balloon occlusion to facilitate elective surgical repair
2
and coil embolization.
3,4
The recent success with an Amplatzer septal occluder device in a pulmonary aneurysm in a patient with tetralogy of Fallot and Eisenmenger syndrome confirms the utility of device closure in patients unsuited to standard surgical intervention.
5
We describe an unconventional use of the Amplatzer muscular ventricular septal defect occluder device for transcatheter closure of an aortic pseudoaneurysm with minimal risk and early complete closure.
References
This article has been cited by other articles:
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  G. Vignati, G. Bruschi, L. Mauri, G. Annoni, M. Frigerio, L. Martinelli, and S. Klugmann Percutaneous device closure of iatrogenic left ventricular wall pseudoaneurysm. Ann. Thorac. Surg., October 1, 2009; 88(4): e31 - e33. [Abstract] [Full Text] [PDF]
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