Abstract
We describe a case of giant pseudoaneurysm of the right pulmonary artery compressing the left atrium after percutaneous pulmonary valve implantation and right pulmonary artery dilatation. Such a complication mimicking an intracavity left atrial mass and treated successfully by stent placement has never, to the best of our knowledge, been reported. (Level of Difficulty: Beginner.)
Key Words: complication, computed tomography, echocardiography, right-sided catheterization
Abbreviations and Acronyms: ESV, Edwards Sapien valve; LPA, left pulmonary artery; RPA, right pulmonary artery
Graphical abstract
We describe a case of giant pseudoaneurysm of the right pulmonary artery compressing the left atrium after percutaneous pulmonary valve implantation…
The authors report a case of a giant pseudoaneurysm of the right pulmonary artery (RPA) that was compressing the left atrium and complicating transcatheter RPA dilatation in a 40-year-old woman with tetralogy of Fallot and left pulmonary artery (LPA) hypoplasia previously treated with ventricular septal defect closure, pulmonary valvotomy, and LPA stenting.
She was found to have residual severe pulmonary regurgitation, stenosis of the proximal RPA, right ventricular dilatation with mildly depressed function, and reduced exercise tolerance. Angiography showed a dilated right ventricle with mildly depressed function, severe pulmonary regurgitation, a good RPA size distally with narrowing just at the takeoff, and a small stented LPA with adequate flow.
She therefore underwent percutaneous pulmonary valve implantation with a size 26 Edwards Sapien valve (ESV) (Edwards Lifesciences, Irvine, California) and RPA dilatation. The procedure was complicated by an intimal tear of the RPA with extravasation into the mediastinum. This tear was treated by giving intravenous protamine sulfate 50 mg, and she was transferred to the intensive care unit. Post-procedural angiography showed a competent ESV, an RPA of good size, and appropriate position of ESV with no gradient.
Three days later, the patient started to report chest pain and underwent transthoracic echocardiography. This imaging showed the presence of a pulsatile cavity in the roof of the left atrium that mimicked a mobile oval mass (2.5 × 1.8 cm), an RPA intimal flap with an inferior tear, and an inferior pseudoaneurysm (Figures 1A to 1C, Videos 1, 2, and 3).
Figure 1.
Giant RPA Pseudoaneurysm Compressing the Left Atrium
(A) Transthoracic echocardiography, parasternal long-axis view, showing a pulsatile mass in the left atrium (LA). The arrow points to the pseudoaneurysm (Video 1). (B) Transthoracic echocardiography, short-axis view, showing a pulsatile mass in the left atrium. The arrow points to the pseudoaneurysm (Video 2). (C) Transthoracic echocardiography, suprasternal long-axis view, showing right pulmonary artery (RPA) dissection, tear of the wall, and the pseudoaneurysm (AN). The arrow points to the intimal dissection (Video 3). (D) Contrast computed tomography, oblique sagittal reformat view, showing extravasation of contrast medium through the right pulmonary artery inferior wall tear into a pocket pseudoaneurysm located between the aortic root and ascending aorta and the left atrium and superior vena cava (SVC) (Video 4). (E) 3-dimensional computed tomography reconstruction images, posterior view of the heart, showing extravasation of contrast medium through the right pulmonary artery inferior wall tear into a pseudoaneurysm located between the aortic root and ascending aorta and the left atrium and superior vena cava. (F) Angiography, right anterior oblique cranial view, showing extravasation of contrast medium into a pseudoaneurysm (arrows) (Video 5). AO = aorta; LPA = left pulmonary artery; LV = left ventricle; MPA = main pulmonary artery; RA = right atrium; RV = right ventricle.
Online Video 1.
Transthoracic Echocardiography, Parasternal Long-Axis View
Left atrial pulsatile mass.
Online Video 2.
Transthoracic Echocardiography, Short-Axis View
Left atrial pulsatile mass.
Online Video 3.
Color Doppler Transthoracic Echocardiography, Suprasternal Long-Axis View
Right pulmonary artery dissection, wall tear, and pseudoaneurysm.
Further, a computed tomography scan with contrast enhancement showed a tear within the inferior portion of the proximal RPA with a pseudoaneurysm between the RPA and the ascending aorta and left atrium (Figures 1D and 1E, Video 4). The ESV was seen in situ and was functioning well; the RPA tree showed good opacification. Angiography confirmed the presence of a pseudoaneurysm (Figure 1F, Video 5).
Online Video 4.
Contrast Computed Tomography of Pulmonary Tree, Oblique Sagittal Reformatted View
Extravasation of contrast medium through the right pulmonary artery inferior wall into a pseudoaneurysm located between the aortic root and ascending aorta and the left atrium and superior vena cava.
Online Video 5.
Angiography Pre-Stent Placement, Right Anterior Oblique Cranial View
Extravasation of contrast medium into a pseudoaneurysm.
Surgery was a possible therapeutic strategy because of the large size of the pseudoaneurysm; however, it was decided to proceed with an endovascular approach and to treat the lesion with stent implantation (1,2). The RPA tear was successfully closed, and there was complete reabsorption in the follow-up. Post-procedural angiography showed the stent in proper position with no residual leak (Video 6). Favorable results were confirmed during patient follow-up.
Online Video 6.
Angiography After Stent Placement, Left Anterior Oblique Cranial View
No extravasation of contrast medium.
Even though pseudoaneurysm is a known complication of percutaneous pulmonary valve implantation, to the best of our knowledge, such a case of giant pseudoaneurysm compressing the left atrium, mimicking an intracavity mass, and successfully treated by stent placement has, to the best of our knowledge, never been reported. Our case provides detailed imaging and highlights the potential of endovascular treatment for such a fearsome complication.
Footnotes
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Case Reportsauthor instructions page.
Appendix
For supplemental videos, please see the online version of this paper.
References
- 1.Ierardi A.M., Xhepa G., Musazzi A.M. Endovascular treatment of a pulmonary artery pseudoaneurysm caused by Swan-Ganz catheter deployment in an anticoagulated patient. BJR Case Rep. 2015;1:20150064. doi: 10.1259/bjrcr.20150064. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Nellaiyappan M., Omar H.R., Justiz R. Pulmonary artery pseudoaneurysm after Swan-Ganz catheterization: a case presentation and review of literature. Eur Heart J Acute Cardiovasc Care. 2014;3:281–288. doi: 10.1177/2048872613520252. [DOI] [PubMed] [Google Scholar]