Author + information
- Received April 27, 2017
- Accepted June 7, 2017
- Published online September 4, 2017.
- Matias B. Yudi, MBBSa,∗ (, )
- Barry Love, MDb,
- Adnan Nadir, MBBSa,
- Annapoorna Kini, MDa and
- Samin K. Sharma, MDa
- aDepartment of Interventional Cardiology, Mount Sinai Medical Center, New York, New York
- bDivision of Pediatric Cardiology, Mount Sinai Medical Center, New York, New York
- ↵∗Address for correspondence:
Dr. Matias Yudi, Mount Sinai Medical Center, Department of Interventional Cardiology, One Gustave L. Levy Place, Box 1030, New York, New York 10029.
A 79-year-old man presented to our institution for follow-up 2 weeks post-delayed presentation of anterior ST-segment elevation myocardial infarction and consequent successful percutaneous coronary intervention to the occluded saphenous vein to left anterior coronary artery graft. He has a past medical history of previous coronary artery bypass surgery, hypertension, hyperlipidemia, and peripheral vascular disease. Echocardiogram (Figure 1A) showed akinetic anteroseptal, inferoseptal, and apical walls with color flow demonstrating a left ventricular pseudoaneurysm. Cardiac magnetic resonance imaging (Figure 1B) and computed tomography angiogram (Figure 1C) confirmed a 34 × 10-mm bilobed left ventricular pseudoaneurysm with a 4-mm neck. A multidisciplinary heart team evaluation deemed the patient to be high risk for surgery, and the decision was made to undertake percutaneous closure. Under fluoroscopic guidance, an 8-F multipurpose guide was placed in the pseudoaneurysm and a 10-mm Amplatzer Muscular VSD Occluder (Abbott Vascular, Santa Clara, California) was successfully deployed via a retrograde transaortic approach (Figure 2B). A follow-up contrast echocardiogram showed continued flow into the pseudoaneurysm (Figure 1D). The patient was brought back to the catheterization laboratory 3 days later for direct chest wall entry into the pseudoaneursym using a micropuncture needle (Figure 2C) with deployment of 14-mm, 10-mm, and 6-mm 0.018-inch Interlock 2D coils (Boston Scientific, Natick, Massachusetts) (Figure 2D). After coil deployment, left ventriculography and echocardiography did not reveal any residual flow into the pseudoaneurysm. The patient was successfully discharged home.
Left ventricular pseudoaneurysms are most commonly a sequelae of myocardial infarction and are associated with an unacceptable risk of sudden cardiac death (1). Although surgery is the preferred treatment strategy, a percutaneous approach is emerging as an appropriate option in high-risk surgical candidates (2,3). Multimodality imaging is essential for diagnosis, to completely understand the pseudoaneurysm anatomy, for procedural planning, and ultimately to guide the intervention. This was particularly highlighted in our case because we initially used a retrograde transaortic approach and then completed the occlusion with a second procedure through an apical approach.
Dr. Sharma is on the Speakers Bureaus of Boston Scientific, Abbott Vascular, Cardiovascular Systems Inc., and TriReme. Dr. Love is a consultant for Abbott. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received April 27, 2017.
- Accepted June 7, 2017.
- 2017 American College of Cardiology Foundation