Article

Percutaneous therapeutic approaches to closure of cardiac pseudoaneurysms

Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.
Catheterization and Cardiovascular Interventions (Impact Factor: 2.4). 10/2012; 80(4):687-99. DOI: 10.1002/ccd.24300
Source: PubMed

ABSTRACT Cardiac and aortic pseudoaneurysms are rare complications following myocardial infarction or cardiac surgery. They are characterized by a contained cardiac or aortic rupture within surrounding tissue and have a high mortality rate if left untreated. Percutaneous treatment of cardiac pseudoaneurysms might be a feasible treatment option in patients who are at high risk of reoperative surgery. There is limited literature on the outcomes and the approaches to percutaneous treatment of these pseudoaneurysms. We review nine cases of cardiac and aortic pseudoaneurysms and percutaneous techniques for closure. Pseudoaneurysms were categorized anatomically as left ventricular posterior (posterobasal or posterolateral), left ventricular outflow tract, left ventricular apical, and ascending aortic pseudoaneurysms. Two patients with posterior pseudoaneurysms (one posterobasal treated with an Amplatzer Septal Occluder device, and one wide-mouthed posterolateral pseudoaneurysm which was not closed, are described. We further describe two left ventricular outflow tract pseudoaneurysms treated successfully with percutaneous coil embolization, one left ventricular apical pseudoaneurysm treated with coils, and three ascending aortic pseudoaneurysms treated with a septal occluder device or vascular plug. We review the technical approaches, device selection strategies, outcomes, and complications with these percutaneous treatment options. The size of the pseudoaneurysm dimensions of its neck and relative anatomy, particularly to the coronaries and valves, are critical issues to be addressed before percutaneous treatment of these pseudoaneurysms. © 2012 Wiley Periodicals, Inc.

1 Follower
 · 
62 Views
  • [Show abstract] [Hide abstract]
    ABSTRACT: A 74-year-old male was referred for mitral valve (MV) surgery because of severe symptomatic mitral regurgitation (MR), caused by annulus dilation and posterior valve restriction (combination of Carpentier's type I and III mechanisms). Left ventricle (LV) was moderately dilated: LV end-diastolic dimension – 59 mm, LV ejection fraction (EF) – 66%. MV annuloplasty with a Carpentier-Edwards 1 Physio ring nr 32 (Edwards Lifesciences, Irvine, CA, USA) was substandard: intraoperative transesophageal echocardiogram (TEE) showed greater than 2 MR, due to excessive tenting. MV replacement appeared to be the best solution. The ring was removed and a bioprosthesis was implanted. The anterior leaflet of the MV was severed 3 mm away from the annulus and its chordae were cut at their insertion to the papillary muscles. The posterior leaflet and its subvalvular apparatus were left intact. The Carpentier-Edwards 1 sizer nr 31 fitted nicely and the bioprosthesis (CarpentierSAV 1 31) was implanted in intra-annular position. Eighteen Teflon-buttressed everted U-shaped Ethibond 00 stitches were used (Teflon pledgets on the atrial side). The stitches on the posterior part of the annulus folded the remaining leaflet prior to being secured to the prosthesis. No abnormal leak or prosthesis rocking was observed by intra-operative TEE (Videos 1 and 2). On pre-discharge transthoracic echocardiogram (TTE) moder-ate compromise of LV function (EF – 35%) and right ventricular dysfunction were noticed (tricuspid annular plane systolic excursion – 15 mm). Mitral prosthesis Doppler parameters were fairly normal (median gradient 7 mmHg, functional area 2.1 cm 2). There was no evidence of paravalvular leak, but an unusual rocking movement of the prosthesis caught our attention (Videos 3.1–3.3). Although this finding was of concern, the absence of heart failure symptoms, infection markers (the patient presented sustained apyrexia and no significant elevation of white blood cells and C-reactive protein), hemodynamic deterioration (blood pressure and heart rate at discharge were 108/76 mmHg and 80 bpm, respec-tively), or major laboratory anomalies (at discharge: hemoglobin 10.2 g/dL, white blood cells 7.23 Â 10 9 /L, C-reactive protein 11.9 mg/L, international normalized ratio 2.15) led us to decide for outpatient care. Rupture of the atrioventricular groove is an uncommon but dreaded complication of mitral valve replacement. We present the case of a 74-year-old male submitted to mitral valve surgery, complicated by atrioventricular groove rupture presaged by the excessive rocking movement of the prosthesis seen in the pre-discharge transthoracic echocardiogram. <Learning objective: Valvular prosthesis rocking movement has been typically associated with paravalvular leaks and fistulae. To the best of our knowledge, this is the first case to illustrate the association of excessive rocking movement with atrioventricular groove weakness, anticipating subsequent sulcus rupture and pseudoaneurysm formation.> ß 2014 Published by Elsevier Ltd on behalf of Japanese College of Cardiology. JCCASE-549; No. of Pages 3 Please cite this article in press as: Sousa A, et al. Marked mitral prosthesis rocking motion preceding atrioventricular groove rupture. J Cardiol Cases (2014),
    Journal of Cardiology Cases 10/2014; DOI:10.1016/j.jccase.2014.09.004
  • [Show abstract] [Hide abstract]
    ABSTRACT: The safety and efficacy of endovascular therapies for ascending aortic pseudoaneurysms (AAPs) are still controversial. We report an endovascular correction of an AAP in a high-risk surgical patient and present the results of a literature review focusing on AAP treatment strategies. A multilingual search of AAP therapy was performed with limiting dates of January 1980 to May 2014. The studies were classified by intervention. A 79-year-old male with a 9 × 10 × 7 cm AAP in the anterior mediastinum was considered too high risk for surgery. An endovascular closure with a 12 mm Amplatzer septal occluder device (St. Jude Medical) was performed, and computed tomography angiography at 3-month follow-up exhibited a thrombosed AAP with minimal residual shunt. In our literature search, we identified 355 cases of AAPs, mostly case reports (91.5%) and a few patient series (8.5%). Surgical correction accounted for 73.8% of the cases, 5% of the patients were conservatively treated or considered too critically ill for any intervention, and 21.2% were treated with endovascular techniques. The most commonly reported endovascular techniques were stent grafts (9.8%) and septal occluder devices (9.8%). Although endovascular closure of AAPs with off-label devices is a reliable option for controlling the expansion and symptoms in high-risk surgical patients, solid data on survival are lacking. Efforts to promote discussion within the heart team to expand the application of endovascular techniques can provide groundbreaking evidence to support the use of endovascular techniques as guideline therapy when facing these complicated cases.
    Ochsner Journal 01/2014; 14(4):576-85.
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Rupture of the atrioventricular groove is an uncommon but dreaded complication of mitral valve replacement. We present the case of a 74-year-old male submitted to mitral valve surgery, complicated by atrioventricular groove rupture presaged by the excessive rocking movement of the prosthesis seen in the pre-discharge transthoracic echocardiogram. Learning objective: Valvular prosthesis rocking movement has been typically associated with paravalvular leaks and fistulae. To the best of our knowledge, this is the first case to illustrate the association of excessive rocking movement with atrioventricular groove weakness, anticipating subsequent sulcus rupture and pseudoaneurysm formation.
    Journal of Cardiology Cases 10/2014;