Author + information
- Received August 10, 2017
- Revision received September 6, 2017
- Accepted September 12, 2017
- Published online January 15, 2018.
- Marco Pavani, MD∗ (, )
- Innocenzo Scrocca, MD,
- Emanuele Meliga, MD and
- Mauro De Benedictis, MD
- ↵∗Address for correspondence:
Dr. Marco Pavani, Interventional Cardiology Unit, A.O. Ordine Mauriziano, Ospedale Umberto I, Turin, Italy.
- cerebral protection device
- ECMO support for challenging percutaneous procedures
- LVPA recurrent embolization
- percutaneous left ventricular pseudoaneurysm closure
A 65-year-old man with a history of inferolateral wall myocardial infarction (MI), complicated by massive mitral regurgitation, treated with biological prosthetic valve implantation (St. Jude Epic 27 mm, St. Jude Medical, St. Paul, Minnesota) and Dacron-patch ventricular repair, was admitted to our hospital with syncope and hemiparesis.
Coronary angiography demonstrated patent coronary arteries, whereas cerebral computed tomography scan showed signs of left frontal lobe infarction. Echocardiography revealed inferior wall left ventricular pseudoaneurysm (LVPA) formation, 66 × 45 mm (neck 14 × 13 mm), likely due to Dacron patch prolapse (Figures 1A and 1B), with a significant thrombotic burden. Left ventricular ejection fraction was severely depressed (16%). Despite therapeutic heparinization, on day 3, the patient experienced an acute anterior MI caused by thrombotic subocclusion of the proximal left anterior descending coronary artery, successfully treated with thrombus aspiration (Figures 2A to 2C). Percutaneous closure of the LVPA was planned by the heart team, because of high surgical risk (EuroSCORE II 51.6%).
A cerebral protection device was deployed (Sentinel Cerebral Protection System, Claret Medical, Santa Rosa, California) via the 6-F right brachial artery (Figure 3) and femoro-femoral extracorporeal membrane oxygenation (ECMO) was implanted. Via the right femoral artery, a 5-F multipurpose catheter was advanced into the LVPA (Figure 4A). A pre-shaped stiff wire (Safari guidewire, Boston Scientific, Natick, Massachusetts) was then positioned (Figure 4B), and the 5-F catheter was replaced with a 80-cm 12-F sheath (Figure 4C). After transesophageal echocardiography (TEE) confirmed the LVPA's neck dimensions, an 18-mm Amplatzer muscular ventricular septal defect occluder (St. Jude Medical) was deployed successfully (Figures 4D, 4E, and 5). A small amount of macroscopic embolic debris was retrieved after cerebral protection device removal (Figure 6). Transthoracic echocardiography performed 48 h after the procedure showed the complete sealing of the LVPA by the occluder device (Figures 7A to 7D).
Chronic LVPA represents a rare complication after MI and myocardial surgical repair, with significant mortality rates (1). Our clinical report describes, for the first time to our knowledge, the feasibility of a percutaneous approach for LVPA exclusion in the complex setting of recurrent embolization and severely impaired left ventricular ejection fraction.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received August 10, 2017.
- Revision received September 6, 2017.
- Accepted September 12, 2017.
- 2018 American College of Cardiology Foundation