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Percutaneous Closure of a Left Ventricular Outflow Tract Pseudoaneurysm Causing Extrinsic Left Coronary Artery Compression by Transseptal Approach

2010; Lippincott Williams & Wilkins; Volume: 121; Issue: 4 Linguagem: Inglês

10.1161/cir.0b013e3181cf2fe2

1524-4539

Rafael Romaguera, Michael Slack, Renata Dejtiar Waksman, Itzik Ben-Dor, Lowell F. Satler, K.M. Kent, S. Goldstein, Z. Wang, P. Corso, Nelson Bernardo, William O. Suddath, A.D. Pichard,

Cardiac Arrhythmias and Treatments

HomeCirculationVol. 121, No. 4Percutaneous Closure of a Left Ventricular Outflow Tract Pseudoaneurysm Causing Extrinsic Left Coronary Artery Compression by Transseptal Approach Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplementary MaterialsFree AccessReview ArticlePDF/EPUBPercutaneous Closure of a Left Ventricular Outflow Tract Pseudoaneurysm Causing Extrinsic Left Coronary Artery Compression by Transseptal Approach R. Romaguera, MD, M.C. Slack, MD, R. Waksman, MD, I. Ben-Dor, MD, L.F. Satler, MD, K.M. Kent, MD, PhD, S. Goldstein, MD, Z. Wang, MD, P. Corso, MD, N. Bernardo, MD, W.O. Suddath, MD and A.D. Pichard, MD R. RomagueraR. Romaguera From the Instituto Cardiovascular, Hospital General Universitatio de Valencia, Valencia, Spain (R.R.), and Children's National Medical Center (M.C.S.) and Interventional Cardiology, Washington Hospital Center (R.W., I.B.-D., L.F.S., K.M.K., S.G., Z.W., P.C., N.B., W.O.S., A.D.P.), Washington, DC. , M.C. SlackM.C. Slack From the Instituto Cardiovascular, Hospital General Universitatio de Valencia, Valencia, Spain (R.R.), and Children's National Medical Center (M.C.S.) and Interventional Cardiology, Washington Hospital Center (R.W., I.B.-D., L.F.S., K.M.K., S.G., Z.W., P.C., N.B., W.O.S., A.D.P.), Washington, DC. , R. WaksmanR. Waksman From the Instituto Cardiovascular, Hospital General Universitatio de Valencia, Valencia, Spain (R.R.), and Children's National Medical Center (M.C.S.) and Interventional Cardiology, Washington Hospital Center (R.W., I.B.-D., L.F.S., K.M.K., S.G., Z.W., P.C., N.B., W.O.S., A.D.P.), Washington, DC. , I. Ben-DorI. Ben-Dor From the Instituto Cardiovascular, Hospital General Universitatio de Valencia, Valencia, Spain (R.R.), and Children's National Medical Center (M.C.S.) and Interventional Cardiology, Washington Hospital Center (R.W., I.B.-D., L.F.S., K.M.K., S.G., Z.W., P.C., N.B., W.O.S., A.D.P.), Washington, DC. , L.F. SatlerL.F. Satler From the Instituto Cardiovascular, Hospital General Universitatio de Valencia, Valencia, Spain (R.R.), and Children's National Medical Center (M.C.S.) and Interventional Cardiology, Washington Hospital Center (R.W., I.B.-D., L.F.S., K.M.K., S.G., Z.W., P.C., N.B., W.O.S., A.D.P.), Washington, DC. , K.M. KentK.M. Kent From the Instituto Cardiovascular, Hospital General Universitatio de Valencia, Valencia, Spain (R.R.), and Children's National Medical Center (M.C.S.) and Interventional Cardiology, Washington Hospital Center (R.W., I.B.-D., L.F.S., K.M.K., S.G., Z.W., P.C., N.B., W.O.S., A.D.P.), Washington, DC. , S. GoldsteinS. Goldstein From the Instituto Cardiovascular, Hospital General Universitatio de Valencia, Valencia, Spain (R.R.), and Children's National Medical Center (M.C.S.) and Interventional Cardiology, Washington Hospital Center (R.W., I.B.-D., L.F.S., K.M.K., S.G., Z.W., P.C., N.B., W.O.S., A.D.P.), Washington, DC. , Z. WangZ. Wang From the Instituto Cardiovascular, Hospital General Universitatio de Valencia, Valencia, Spain (R.R.), and Children's National Medical Center (M.C.S.) and Interventional Cardiology, Washington Hospital Center (R.W., I.B.-D., L.F.S., K.M.K., S.G., Z.W., P.C., N.B., W.O.S., A.D.P.), Washington, DC. , P. CorsoP. Corso From the Instituto Cardiovascular, Hospital General Universitatio de Valencia, Valencia, Spain (R.R.), and Children's National Medical Center (M.C.S.) and Interventional Cardiology, Washington Hospital Center (R.W., I.B.-D., L.F.S., K.M.K., S.G., Z.W., P.C., N.B., W.O.S., A.D.P.), Washington, DC. , N. BernardoN. Bernardo From the Instituto Cardiovascular, Hospital General Universitatio de Valencia, Valencia, Spain (R.R.), and Children's National Medical Center (M.C.S.) and Interventional Cardiology, Washington Hospital Center (R.W., I.B.-D., L.F.S., K.M.K., S.G., Z.W., P.C., N.B., W.O.S., A.D.P.), Washington, DC. , W.O. SuddathW.O. Suddath From the Instituto Cardiovascular, Hospital General Universitatio de Valencia, Valencia, Spain (R.R.), and Children's National Medical Center (M.C.S.) and Interventional Cardiology, Washington Hospital Center (R.W., I.B.-D., L.F.S., K.M.K., S.G., Z.W., P.C., N.B., W.O.S., A.D.P.), Washington, DC. and A.D. PichardA.D. Pichard From the Instituto Cardiovascular, Hospital General Universitatio de Valencia, Valencia, Spain (R.R.), and Children's National Medical Center (M.C.S.) and Interventional Cardiology, Washington Hospital Center (R.W., I.B.-D., L.F.S., K.M.K., S.G., Z.W., P.C., N.B., W.O.S., A.D.P.), Washington, DC. Originally published2 Feb 2010https://doi.org/10.1161/CIR.0b013e3181cf2fe2Circulation. 2010;121:e20–e22A 44-year-old man underwent aortic valve replacement with a porcine bioprosthesis 21 years ago for infective endocarditis complicated by a cerebral mycotic aneurysm and intracranial bleeding. Nine years ago, he had a second aortic valve replacement with a mechanical bileaflet tilting-disk prosthesis because of porcine prosthesis degeneration. No pseudoaneurysm was noted on the operative report. Six months ago, he developed angina and had a positive stress test for ischemia. Angiography showed severe left main coronary artery (LM) stenosis, which was treated with intravascular ultrasound–guided percutaneous coronary intervention with a zotarolimus-eluting stent.Two months ago, he again developed angina. Follow-up angiography and intravascular ultrasound revealed severe in-stent restenosis in the proximal third of the LM and systolic narrowing of the distal third, suggestive of extrinsic compression (Figure 1 and online-only Data Supplement Movie 1). In-stent restenosis was treated at that time with a sirolimus-eluting stent. A transesophageal echocardiogram revealed a large pseudoaneurysm lateral to the aortic root; color Doppler (Figure 2A and online-only Data Supplement Movie 2) demonstrated systolic filling through a communication to the left ventricular outflow tract. A 256-slice cardiac multidetector computed tomography (Figure 3) assessed the relation and distance between the edge of the pseudoaneurysm opening and the aortic mechanical prosthesis. Download figureDownload PowerPointFigure 1. Coronary angiography (A, systole; B, diastole) reveals severe in-stent restenosis caused by intimal hyperplasia in the proximal third (black arrow) of the LM but also extrinsic systolic compression of the middle and distal thirds (white arrows). C, Intravascular ultrasound of the middle third confirms systolic compression. D, The final result of the percutaneous coronary intervention was excellent.Download figureDownload PowerPointFigure 2. A, Transesophageal echocardiogram shows a large pseudoaneurysm (PsA) with systolic filling through the left ventricular (LV) outflow tract. B, A 6-month follow-up transthoracic echocardiogram with contrast confirms complete closure.Download figureDownload PowerPointFigure 3. Cardiac computed tomography. A, Oblique coronal multiplanar reformat confirms a 2.6×3.6-cm pseudoaneurysm compressing the LM. B, Volume-rendering reconstruction of the left ventricle, aorta, and pseudoaneurysm. C, Electrophysiological planning protocol (Philips) shows the relation between the pseudoaneurysm (green), aorta-LM (pink), LV (sky blue), and LA (deep blue).In view of the high surgical risk, percutaneous treatment was planned. Transseptal approach to the left ventricle was obtained under intracardiac echocardiography and fluoroscopic guidance. A 6F Swan-Ganz balloon catheter was advanced into the pseudoaneurysm (Figure 4A and online-only Data Supplement Movie 3) and exchanged for an Amplatzer 7F delivery catheter. A 10-mm Amplatzer muscular ventricular septal defect occluder device (AGA Medical Corp, Plymouth, Minn) was successfully deployed in the neck of the aneurysm (online-only Data Supplement Movie 4). Intracardiac echocardiography and aortography (Figure 4B and online-only Data Supplement Movie 5) confirmed an excellent relation of the device with aortic prosthesis, and ventriculography (Figure 4C and online-only Data Supplement Movie 6) demonstrated the exclusion of the pseudoaneurysm. The patient did well and was discharged the next day. Six months after the procedure, the patient remained asymptomatic, and a transthoracic echocardiogram with contrast (Definity, Lantheus Medical Imaging, North Billerica, Mass) confirmed complete closure (Figure 2B and online-only Data Supplement Movie 7). Download figureDownload PowerPointFigure 4. A, Angiography with a Swan-Ganz catheter in the pseudoaneurysm. B, Left anterior oblique aortography shows excellent positioning of the device. C, Right anterior oblique ventriculography confirms complete isolation of the pseudoaneurysm. White arrows show the device.Left ventricular outflow tract pseudoaneurysm is an uncommon complication in patients with a history of infective endocarditis.1 In addition, few cases have been reported after aortic surgery in the absence of endocarditis. Although some patients may remain asymptomatic, serious complications can occur, including cardiac tamponade caused by rupture into the pericardium, peripheral embolization, or severe mitral regurgitation. A few cases of angina have also been reported. It has been suggested that systolic beat-to-beat impingement may lead to endothelial hyperplasia2 of the coronary arteries, which is consistent with the intravascular ultrasound findings in the LM of this patient. Surgical repair plus coronary bypass when coronary arteries are involved is recommended even if the patient is asymptomatic to prevent those complications. Because of the high surgical risk and the complexity of that procedure, percutaneous treatment may be considered. Transaortic percutaneous closure of a mitral-aortic intervalvular fibrosa pseudoaneurysm was reported by Jimenez et al,3 with excellent results. In addition, successful percutaneous coronary intervention of the LM for extrinsic compression by pulmonary artery has been described in 2 cases4 with good midterm outcome.To the best of our knowledge, this is the first description of successful transseptal approach of a left ventricular outflow tract pseudoaneurysm causing LM compression in a patient with mechanical aortic valve prosthesis. This technique is an alternative to surgery in selected patients with this uncommon condition.The online-only Data Supplement is available with this article at http://circ.ahajournals.org/cgi/content/full/121/4/e20/DC1.DisclosuresNone.FootnotesCorrespondence to Ron Waksman, MD, Washington Hospital Center, 110 Irving St NW, Suite 4B-1, Washington, DC 20010. E-mail [email protected]References1 Karalis DG, Bansal RC, Hauck AJ, Ross JJ Jr, Applegate PM, Jutzy KR, Mintz GS, Chandrasekaran K. Transesophageal echocardiographic recognition of subaortic complications in aortic valve endocarditis, clinical and surgical implications. Circulation. 1992; 86: 353–362.CrossrefMedlineGoogle Scholar2 Parashara DK, Jacobs LE, Kotler MN, Yazdanfar S, Spielman SR, Janzer SF, Bemis CE. Angina caused by systolic compression of the left coronary artery as a result of pseudoaneurysm of the mitral-aortic intervalvular fibrosa. Am Heart J. 1995; 129: 417–421.CrossrefMedlineGoogle Scholar3 Jimenez S, Garcia E, Gonzalez A, Delcan JL. Percutaneous closure of pseudoaneurysm of the mitral-aortic intervalvular fibrosa. Rev Esp Cardiol. 2005; 58: 1473–1475.CrossrefMedlineGoogle Scholar4 Rich S, McLaughlin VV, O'Neill W. Stenting to reverse left ventricular ischemia due to left main coronary artery compression in primary pulmonary hypertension. Chest. 2001; 120: 1412–1415.Movie 1. Coronary angiography revealed extrinsic systolic compression of the left main stenosis. Best viewed with Windows Media Player. Movie 2. Transesophageal echocardiography demonstrated systolic filling through a communication lateral to the aortic root. Best viewed with Windows Media Player. Movie 3. A 6F Swan-Ganz balloon catheter was advanced into the pseudoaneurysm. Best viewed with Windows Media Player. Movie 4. A 10-mm Amplatzer muscular ventricular septal defect occluder device (AGA Medical Corp, Plymouth, Minn) was successfully deployed in the neck of the aneurysm. Best viewed with Windows Media Player. Movie 5. Aortography confirmed an excellent relation between the device and the aortic prosthesis. Best viewed with Windows Media Player. Movie 6. Ventriculography confirmed isolation of the pseudoaneurysm. Best viewed with Windows Media Player. Movie 7. Transthoracic echocardiogram with contrast at 6 months confirmed complete closure. Best viewed with Windows Media Player.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Sonawane B and Sivakumar K (2020) A giant left ventricular pseudoaneurysm diagnosed after double-valve replacement, Asian Cardiovascular and Thoracic Annals, 10.1177/0218492320983490, 29:9, (953-956), Online publication date: 1-Nov-2021. Mikami T, Yoshioka D, Kawamura T, Toda K, Sawa Y and Miyagawa S (2021) Active infective endocarditis of a bicuspid aortic valve causing left ventricular outflow tract pseudoaneurysm and right atrium shunt: A case report, International Journal of Surgery Case Reports, 10.1016/j.ijscr.2021.106527, 88, (106527), Online publication date: 1-Nov-2021. Neeraj A, Kumar V, Bisht D and Kumar V (2020) Percutaneous closure of a left ventricular pseudoaneurysm: Case report with review of cases, IHJ Cardiovascular Case Reports (CVCR), 10.1016/j.ihjccr.2020.08.006, 4:3, (104-107), Online publication date: 1-Sep-2020. 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Percutaneous treatment: which to treat first, the trunk or the pseudoaneurysm?, EuroIntervention, 10.4244/EIJ-D-16-01042, 13:15, (e1814-e1815) Ota H, Morita Y, Saiki Y and Takase K (2017) Coil embolization of left ventricular outflow tract pseudoaneurysms: techniques and 5-year results, Interactive CardioVascular and Thoracic Surgery, 10.1093/icvts/ivw394, (ivw394) February 2, 2010Vol 121, Issue 4 Advertisement Article InformationMetrics https://doi.org/10.1161/CIR.0b013e3181cf2fe2PMID: 20124133 Originally publishedFebruary 2, 2010 PDF download Advertisement SubjectsCatheter-Based Coronary and Valvular InterventionsComputerized Tomography (CT)EchocardiographyImagingInfectious EndocarditisValvular Heart Disease