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A Guidewire-Free Approach for Percutaneous Closure of Left Ventricular Pseudoaneurysm
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A 78-year-old male patient with a history of coronary artery disease (he had undergone coronary artery bypass surgery 4 years ago), heart failure with mildly reduced ejection fraction, diabetes mellitus, and transient ischemic attack presented to the emergency department with complaints of dyspnea (New York Heart Association Class 4) despite the optimal medical therapy. Transthoracic echocardiography (TTE) revealed a huge left ventricular inferolateral wall pseudoaneurysm filling with a leak (Figure, A and B; Videos 1-3). The size of the pseudoaneurysm neck was 36 mm, and the pseudoaneurysm was 54 x 75 mm on cardiac computed tomography (Figure, C and D). The wall of the pseudoaneurysm was fragile, and the patient was a high-risk candidate for surgical treatment of the pseudoaneurysm. Therefore, the heart team decided to close the pseudoaneurysm percutaneously.
However, there was no ventricular septal defect occluder of a suitable size for the wide neck of this pseudoaneurysm, so we decided to use an atrial septal defect (ASD) occluder. Two right femoral venous sheaths and 1 right femoral arterial sheath were placed. One femoral vein cannulation was used for coronary sinus catheter placement, which provided anatomical guidance. The other femoral vein cannulation was used for atrial septostomy. Arterial cannulation was used for the pigtail catheter to perform the left ventriculography. Left ventriculography showed the site of the pseudoaneurysm, the neck of the pseudoaneurysm, and the size and extent of the lesion (Video 4). After the atrial septostomy, the delivery sheath was moved to the left ventricular cavity. Due to the possibility of pseudoaneurysm wall rupture, an ablation catheter was used instead of a guidewire to carry the sheath. The ablation catheter was easily guided to the neck of the pseudoaneurysm, and the sheath was advanced safely through this catheter (Figure, E; Video 5). A 38-mm Amplatzer ASD occlude (Abbott) was deployed into the pseudoaneurysm, ensuring the left atrial disc was deployed in the pseudoaneurysm and the right atrial disc was deployed in the left ventricle (Figure, F; Video 6).
After the procedure, TTE confirmed the closure of the pseudoaneurysm, and the patient was discharged the next day (Figure, G and H; Videos 7 and 8). At 6-month follow-up, the patient was not admitted to the hospital due to decompasated heart failure, and control cardiac computed tomography revealed the ASD device was in the proper position and the pseudoaneurysm had shrunk (Figure, I and J).
Left ventricular pseudoaneurysm is a rare but potentially lethal complication of myocardial infarction. Untreated pseudoaneurysms have a 30% to 45% risk of rupture within the first year, and surgical repair of the left ventricular pseudoaneurysm carries a high risk of morbidity and mortality, with a mortality rate of 20% to 36%. Although surgical repair is the preferred method for left ventricular pseudoaneurysm, cardiac surgery has higher morbidity and mortality rates. Therefore, percutaneous closure is an alternative method that may be preferred in high-risk patients. While a ventricular septal defect occluder is mainly used for percutaneous closure, an ASD occluder may be used for wide neck pseudoaneurysms, as in our case. The sheath placed to carry the ASD device was always sent into the pseudoaneurysm with a guidewire. However, with this method, the possibility of rupture of the thin pseudoaneurysm wall increases considerably. In this case, we demonstrated a novel technique to guide the sheath into the pseudoaneurysm easily and safely with an ablation catheter without using a guidewire.
Affiliations and Disclosures
From the 1Department of Cardiology, Gebze Fatih State Hospital, Heart Center, Kocaeli, Turkey; 2Department of Cardiology, Akademi Hospital, Kocaeli, Turkey; 3Faculty of Health Sciences, Kocaeli Health and Technology University, Kocaeli, Turkey.
Disclosures: The authors report no financial relationships or conflicts of interest
regarding the content herein.
Address for correspondence: Aziz Inan Celik, MD, Osman Yilmaz neighborhood, Istanbul street, 127, Department of Cardiology, Gebze Fatih State Hospital, Heart Center, Kocaeli 41400, Turkey. Email: azizinanmd@hotmail.com
