Author + information
- Received July 17, 2012
- Accepted August 2, 2012
- Published online December 1, 2012.
- Anna E. Bortnick, MD, PhD⁎,†,
- Emily Gordon, MD‡,
- Jacob Gutsche, MD‡,
- Saif Anwaruddin⁎,
- Wilson Y. Szeto, MD§,
- Nimesh Desai, MD§,
- Prashanth Vallabhajosyula, MD§,
- Joseph E. Bavaria, MD§ and
- Howard C. Herrmann, MD⁎,⁎ ()
- ↵⁎Reprint requests and correspondence
: Dr. Howard C. Herrmann, Interventional Cardiology and Cardiac Catheterization Laboratories, Hospital of the University of Pennsylvania, 34th and Spruce Streets, Philadelphia, Pennsylvania 19104
An 87-year-old woman with severe aortic stenosis (aortic valve area: 0.6 cm2, mean gradient: 60 mm Hg, ejection fraction: 80%) was referred for transcatheter aortic valve replacement. She was high risk for open aortic valve replacement (Society of Thoracic Surgeons class 10.6) due to a history of chronic hepatitis on azathioprine, coronary artery disease, atrial fibrillation, multiple falls with hip and clavicular fractures, and frailty (body mass index: 15.6 kg/m2). The procedure was performed transapically due to poor peripheral access. She underwent a left mini thoracotomy and a 23-mm Sapien XT prosthesis (Edwards Lifesciences, Irvine, California) was inserted via the Ascendra 2 delivery system (Edwards Lifesciences). Two perpendicular, pledgeted horizontal mattress sutures were placed in the muscular portion of the anterior left ventricular (LV) apex. The pledgeted sutures were tied down under rapid ventricular pacing at completion of the procedure and after removal of the sheath. There was satisfactory hemostasis, a third anchoring suture was placed as a precaution, and chest closure was performed. The patient was discharged on post-operative day 6.
Two weeks after the procedure, the patient presented to an outside hospital with left-sided abdominal pain and bilious vomiting. Computed tomography demonstrated a small bowel obstruction. There was an incidental finding of a 19 × 31 × 27 mm contrast-filled structure adjacent to the LV, and she was transferred for further management. A transthoracic echocardiogram with contrast confirmed the presence of an LV pseudoaneurysm with a 3.5-mm neck (Fig. 1A) (Online Video 1). LV pseudoaneurysm is a recognized but rare complication and has implications for the delivery of other devices through the LV apex (1–3).
After discussion with the patient and her family, a decision was made to proceed with percutaneous closure of the pseudoaneurysm using a 6-mm Amplatzer muscular Ventricular Septal Defect Occluder (St. Jude Medical Inc., St. Paul, Minnesota) via a retrograde approach from the right femoral artery. The procedure was performed in a hybrid operating room with fluoroscopic and transesophageal echocardiographic guidance (Fig. 1B) (Online Video 2).
The tract was crossed with a 6-F multipurpose diagnostic catheter and a 0.035-inch Terumo Glidewire (Terumo Medical Corp., Somerset, New Jersey). A complex structure, consisting of a small upper pouch communicating with a lower, larger pouch was seen on selective angiography (Fig. 1C). A 0.035-inch exchange length Amplatz Extra Stiff wire (Cook Medical, Bloomington, Indiana) was advanced through the multipurpose diagnostic catheter and used to exchange for an 8-F multipurpose guide catheter. The muscular Ventricular Septal Defect Occluder device was deployed and released (Fig. 1D). Final ventriculography showed no flow into the pseudoaneurysm and a stable muscular Ventricular Septal Defect Occluder closure device in the wall of the LV (Fig. 1E) (Online Video 3). The patient tolerated the procedure and was discharged 5 days after procedure once the small bowel obstruction resolved.
Dr. Bortnick has received partial salary support from a grant to her department by Abbott Vascular. Drs. Anwaruddin, Szeto, and Desai have served as subprincipal investigators of the PARTNER trial. Dr. Szeto has served on the PARTNER Trial Steering Committee, as a consultant for Microinterventional Devices and received a research grant from Edwards LifeSciences. Drs. Bavaria and Herrmann have served as principal investigators of the Edwards Lifesciences PARTNER trial. Dr. Herrmann has received research funding from the institution and speaking honoraria from Edwards Lifesciences, consulting fees from St. Jude Medical and Paeion, and has equity in Microinterventional Devices. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received July 17, 2012.
- Accepted August 2, 2012.
- American College of Cardiology Foundation