Percutaneous occlusion of a pseudoaneurysm evolving after homograft aortic valve and root replacement with the Amplatzer muscular ventricular septal defect occluder

Contemporary experience of percutaneous management of complex aortic and ventricular pseudoaneurysms associated to perivalvular leak: A case series and review of literature

BACKGROUND

Percutaneous closure of aortic and ventricular pseudoaneurysms (PSA) has only been reported on a case report and series basis. In previous case reports, percutaneous closure has been performed successfully in patients of prohibitive surgical risk. This case series aims to show feasibility of percutaneous closure of aortic and ventricular pseudoaneurysm secondary to perivalvular leak (PVL) in a small patient population and the utility of multimodality imaging as an integral tool in procedural planning. This is the largest complex case series to date describing the feasibility and success rate of complex PSA closure, with a follow-up period of up to 4 years.

MATERIAL AND METHODS

We performed institutional review and systemic literature review to identify all paravalvular leak cases with associated pseudoaneurysm formation for which a closure procedure was performed. Ten patients were identified. Pooled analysis for cases from institutional review (n = 10) and systemic literature review (n = 39) was performed. The success rate was 100 %. At 30-days, the mortality was 0 %.

CONCLUSION

In paravalvular leak patients with subsequent pseudoaneurysm formation, exhaustive imaging evaluation is required for closure. However, it can be achievable with favorable rates of success.

Percutaneous closure of left ventricular pseudoaneurysm

The aim of the present study is to describe the indications, treatment effects, and patient outcomes of percutaneous management of left ventricular pseudoaneurysm (LVPA). The study materials were based on comprehensive literature retrieval since 2004. The mechanisms of LVPA formation can be divided into surgical, percutaneous, and medial disease related. Of the surgical mechanisms, coronary artery bypass grafting prevailed. The formation time was the longest in medical disease-related LVPAs up to 44.4 months. The percutaneous procedures succeeded on the first try in 79 (84.9%) patients, whereas failures were encountered during the percutaneous manoeuvres in 14 (15.1%) patients. Percutaneous closure of LVPA was especially indicated for patients carrying a high surgical risk. The iatrogenic traumas, such as left ventricular venting, should be avoided to prevent this complication. The preliminary cut-off valves of oversize 3.3 mm and oversize ratio 1.6 should be followed for reference for device choice.

Percutaneous device closure of a large complex aortic root pseudoaneurysm

Pseudoaneurysm of the aorta is a rare and high-risk complication of native aortic valve endocarditis and can develop following cardiac surgery for aortic valve and root disease. If left untreated, there is a significant risk of aortic wall rupture and fatality. Given the high risk of mortality associated with traditional open surgical repair of aortic pseudoaneurysms, endovascular approach is a potentially favourable alternative. We describe a unique case of a young woman with a large and complex paraprosthetic pseudoaneurysm with multiple communicating fistulae which was successfully percutaneously treated with two occluder devices. In this technically challenging case, a minor but unique procedural complication is also illustrated.

Transcatheter device closure of pseudoaneurysms of the left ventricular wall: An emerging therapeutic option

Left ventricular pseudoaneurysm is a rare but serious complication of acute myocardial infarction and cardiac surgery. While surgical intervention is the conventional therapeutic option, transcatheter closure can be considered in selected patients with suitable morphology of the pseudoaneurysm. We report a case of successful transcatheter closure of a left ventricular pseudoaneurysm orifice and isolation of the sac using an Amplatzer septal occluder.

Salvage periaortic pericardial baffle equalizes mortality in bleeding patients undergoing aortic surgery

OBJECTIVE

Bleeding is a potentially serious complication of aortic surgery. We report our experience with the use of a periaortic bovine pericardial baffle to control intractable intraoperative bleeding.

METHODS

All patients who underwent aortic root, ascending, or arch replacements between January 2002 and April 2013 were reviewed. A bovine pericardial periaortic baffle was created to shunt shed blood into the right atrium. The transverse sinus was sutured closed in patients undergoing primary sternotomy. Baffle recipients were compared with the remaining patients undergoing aortic surgery. The Fisher exact test was used to determine statistical significance for categoric variables. Continuous variables were compared using the nonparametric Wilcoxon rank-sum test. All factors with a P value less than .2 were considered for multivariate logistic regression to determine independent associations with baffle use.

RESULTS

A total of 413 patients were identified, of whom 23 received a baffle. Operative mortality for patients receiving a baffle was 4% (1/23) compared with 6% (25/390) (P = 1) for the remaining patients. Prolonged ventilation was more common in the baffle recipients (P < .0005); otherwise, there were no differences in postoperative morbidity. Multivariate analysis of all patients undergoing aortic surgery revealed infectious endocarditis (P < .0005; odds ratio, 15.1; 95% confidence interval, 4.8-47.2), redo sternotomy (P < .0005; odds ratio, 11.9; 95% confidence interval, 4.1-34.1), and male gender (P = .04; odds ratio, 4.6; 95% confidence interval, 1.1-19.3) to be predictive of baffle placement.

CONCLUSIONS

Patients requiring salvage periaortic pericardial baffle for intractable intraoperative hemorrhage experienced an operative mortality similar to that in the remaining patients undergoing aortic surgery. Infectious endocarditis requiring root replacement or reoperative aortic surgery should alert the surgeon to the potential need for baffle placement, including prophylactic transverse sinus closure.

Percutaneous closure of left ventricular pseudoaneurysm

The risk of rupture of a left ventricular (LV) pseudoaneurysm ranges from 30% to 45% in the first year. Open surgical repair carries high mortality related to anatomic complexity and patient comorbidities. Percutaneous closure may offer a viable alternative to surgical intervention in this cohort. Herein, we describe 3 unique cases of transcatheter LV pseudoaneurysm closure.

Percutaneous device closure of iatrogenic left ventricular wall pseudoaneurysm

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.

Use of a percutaneous septal occlusion device to exclude a juxta-renal pseudoaneurysm of the abdominal aorta

Abdominal aortic pseudoaneurysm is an uncommon, but challenging condition. The most common etiologies are either trauma or iatrogenic repair via open surgery, endovascular aortic cuff, and exclusion via placement of coils has been described. We describe a case of a juxta-renal aortic pseudoaneurysm following aorto-bi-iliac bypass grafting that was successfully excluded by endovascular placement of a percutaneous septal occlusion device.

Percutaneous closure of left ventricular free wall rupture with associated false aneurysm to prevent cardioembolic stroke

Left ventricular (LV) false aneurysm is an uncommon complication of myocardial infarction. Conventional treatment mandates surgical repair but is associated with significant perioperative risk. We present a case of successful percutaneous closure of a LV false aneurysm in a patient at high operative risk who suffered cardioembolic stroke related to thrombus within the aneurysm. The primary aim of treatment was to prevent recurrent embolic event.