Percutaneous Closure of a Left Ventricular Pseudoaneurysm in a High-Risk Surgical Candidate

Abstract

Few cases of percutaneous device closure of a left ventricular pseudoaneurysm have been reported. We describe the case of a 67-year-old man with a history of coronary artery disease who presented with shortness of breath and chest pain. Computed tomographic angiography showed a left ventricular pseudoaneurysm that was filling from a small leak in the anterolateral aspect of the ventricle. The patient had undergone 3 previous sternotomies and was a high-risk candidate for surgical treatment of the pseudoaneurysm. Despite technical challenges, we closed the pseudoaneurysm percutaneously with use of a 6-mm AMPLATZER muscular ventricular septal defect occluder. The patient was released from the hospital the next day and was asymptomatic a year later.

To our knowledge, this is the first report of the percutaneous closure of a left ventricular pseudoaneurysm via the femoral vein. We show that this manner of closure can be feasible in patients who have undergone multiple sternotomies and who are at high surgical risk.

A left ventricular (LV) pseudoaneurysm is a small channel that connects the LV to a large aneurysmal sac that contains blood and thrombus.¹ Complications of a pseudoaneurysm include rupture into the pericardium, peripheral embolization, and severe mitral regurgitation.² Emergent surgical repair is the preferred method of closing a pseudoaneurysm³; however, patients who have previously undergone cardiac surgery have a higher risk of morbidity and death after reoperation.^4,5 We describe the percutaneous closure of a pseudoaneurysm of the LV in a high-risk surgical candidate.

Case Report

A 67-year-old man with a history of coronary artery disease presented with recurring shortness of breath and chest pain. One year before the current admission, he had undergone 3-vessel coronary artery bypass grafting (CABG) that was complicated by a postoperative mediastinal hematoma. The mediastinal cavity was re-explored and the hematoma was evacuated. Postoperatively, the patient sustained an inferior-wall myocardial infarction with congestive heart failure. When his condition was stable and his estimated LV ejection fraction (LVEF) was 0.50, he was discharged from the hospital.

Two months thereafter, routine echocardiography revealed mild-to-moderate LV systolic dysfunction (LVEF, 0.40). Cardiac magnetic resonance imaging showed a thin, dyskinetic, aneurysmal cardiac apex and distal septum that contained a thin, layered thrombus. Long-axis view showed a cavity (area, 2.7 × 2.3 cm) adjacent to the lateral wall. Flow entered the cavity during systole, indicating connection with the main ventricular chamber. After 10 days, the patient returned to the hospital with worsening dyspnea, cough, and fluid retention, indicative of severe congestive heart failure. Echocardiography revealed an LVEF of 0.16 and a ruptured LV pseudoaneurysm. The pseudoaneurysm was emergently resected, and an intra-aortic balloon pump was inserted to improve hemodynamic stability. After 2 months, the patient was discharged from the hospital.

During the current admission (6 months after the patient's last operation), contrast-enhanced computed tomography of the chest showed cardiomegaly and an area of high attenuation—possibly a pseudoaneurysm—adjacent to the LV apex (Fig. 1). Computed tomographic angiography of the heart confirmed the presence of a 2.4 × 2.9-cm LV pseudoaneurysm of the distal lateral wall. The patient had undergone 3 prior sternotomies and would have been at high risk if another were to be attempted, so we decided to close the pseudoaneurysm percutaneously.

Fig. 1 Computed tomogram of the chest shows a left ventricular pseudoaneurysm (arrow).

A pigtail catheter was inserted through the right femoral vein and into the LV cavity. Left ventriculography, with the injection of contrast medium, was performed in the right and left anterior oblique projections to reveal the sites of the pseudoaneurysm and the leak. The pseudoaneurysm was filling from a small leak in the anterolateral aspect of the ventricle (Fig. 2), which was similar to the results shown by computed tomographic angiography.

Fig. 2 Left ventriculogram (right anterior oblique projection) shows the catheter injection of contrast medium into the pseudoaneurysm (arrow).

To locate the exact site of the leak, a 6F Judkins right 4 diagnostic catheter was used to inject small amounts of iodine into the region of the pseudoaneurysm. A 0.035-in STORQ® guidewire (Cordis Endovascular Systems, Inc., a Johnson & Johnson company; Miami Lakes, Fla) was gently passed across the leak into the pseudoaneurysm, and the tip of the wire was curved to avoid perforating the pseudoaneurysm (Fig. 3). An 8F arrow sheath was passed through the narrow neck and into the main cavity of the pseudoaneurysm. Multiple attempts to insert a 6-mm AMPLATZER® muscular ventricular septal defect (VSD) occluder (St. Jude Medical, Inc.; St. Paul, Minn) into the pseudoaneurysm were unsuccessful because of the tortuosity of the aorta, the necessary 90° turn in the LV cavity, longitudinal friction, and the difficulty of pushing the occluder along a coaxial path.

Fig. 3 Left ventriculogram shows a wire (arrow) that was placed inside the pseudoaneurysm through a 6F Judkins right 4 guiding catheter.

Finally, a 100-cm 6F multipurpose sheath was fed inside the arrow sheath and placed into the pseudoaneurysm. The delivery cable of the AMPLATZER occluder was exchanged for one from a larger device, to provide better push for the occluder. With continuous flushing to decrease friction, the occluder was delivered and deployed in standard fashion across the LV myocardial wall. Left ventricular angiography confirmed the closure of the pseudoaneurysm (Fig. 4). The patient was discharged from the hospital the next day. An echocardiogram 6 months later showed a moderate decrease in overall LV systolic function and an ejection fraction of 0.40. Definity® contrast agent (Lantheus Medical Imaging; N. Billerica, Mass) showed no significant residual leakage. One year after the procedure, the patient was asymptomatic.

Fig. 4 Left ventriculogram shows occlusion of the pseudoaneurysm with use of a 6-mm AMPLATZER® muscular ventricular septal defect occluder (arrow).

Discussion

Left ventricular pseudoaneurysm is a very rare sequela of myocardial infarction and myocardial surgery. If a pseudoaneurysm is untreated, the risk of its rupture within the first year is 30% to 45%; in contrast, the reported mortality rate associated with surgical repair is less than 20%.⁶ Although emergent surgical repair is the preferred method of closing an LV pseudoaneurysm,³ patients who have previously undergone cardiac surgery have higher rates of morbidity and mortality after reoperation.^4,5 Accordingly, we decided that attempting percutaneous closure of our patient's pseudoaneurysm was prudent and feasible.

Percutaneous closure of atrial and ventricular septal defects has been widely performed, and the procedure is typically safe and well tolerated: the risk of cardiac perforation in catheter-based procedures is less than 1%.³ Given the size and location of our patient's pseudoaneurysm, we chose a device that was designed for VSD closure.

One technical challenge of percutaneous closure was to locate and cross the neck of the pseudoaneurysm by using adequately long sheaths. Another challenge was that of pushing the VSD occluder with use of a coaxial guiding catheter and delivery cable. For this, the delivery cable from a larger device was useful.

Few cases have been reported of percutaneous device closure of LV pseudoaneurysms. In 2004, Clift and colleagues⁷ reported the first percutaneous repair of an LV pseudoaneurysm via the brachial artery. To our knowledge, ours is the second description of the percutaneous repair of an LV pseudoaneurysm in a patient who had undergone prior CABG and LV aneurysmectomy. This is the first report of the use of this technique via the femoral vein in a patient who had undergone multiple sternotomies. We found that the percutaneous closure of an LV pseudoaneurysm with use of a muscular VSD occluder device was feasible in our high-risk patient, who had undergone 3 previous sternotomies. Further evidence is needed to confirm the safety and efficacy of this approach in similar patients.