Author + information
- Received May 19, 2014
- Accepted May 22, 2014
- Published online November 1, 2014.
- Takashi Matsumoto, MD,
- Kazuaki Okuyama, MD,
- Wen Cheng, MD,
- Raj R. Makkar, MD and
- Saibal Kar, MD∗ ()
- ↵∗Reprint requests and correspondence:
Dr. Saibal Kar, Heart Institute, Cedars-Sinai Medical Center, 8631 West Third Street, Room 415E, Los Angeles, California 90048.
- left ventricular pseudoaneurysm
- percutaneous closure
- transcatheter aortic valve replacement
- transseptal approach
An 81-year-old woman presented for a scheduled 1-month follow-up after an uneventful valve-in-valve transapical transcatheter aortic valve replacement (TA-TAVR) using a 23-mm Sapien XT prosthesis (Edwards Lifesciences, Irvine, California). Although the patient remained asymptomatic after discharge, a transthoracic echocardiogram revealed a left ventricular (LV) pseudoaneurysm, with a 10-mm neck, at the location of the transapical access site (Figure 1A, Online Video 1). Subsequent heart team discussion led to the decision to proceed with percutaneous closure via an antegrade transseptal approach. The procedure was performed under general anesthesia and transesophageal echocardiographic guidance. Following transseptal puncture, an 8-F Mullins sheath was further advanced into the LV through the mitral valve with a support of a 6-F balloon floating catheter, and then an initial LV angiogram was performed (Figure 2A). A 6-F multipurpose catheter was manipulated into the pseudoaneurysm; the catheter was then exchanged for an 80-cm 8-F Amplatzer TorqVue sheath (St. Jude Medical, Minneapolis, Minnesota). On the basis of echocardiographic and balloon-sizing measurement, a 12-mm Muscular ventricular septal defect occluder (St. Jude Medical) was prepared in standard fashion and deployed successfully (Figures 2B and 2C). The final angiogram showed a well-seated device without significant shunt (Figure 2D). At discharge (post-operative day 2), a transthoracic echocardiogram showed the occluder device completely sealing the pseudoaneurysm (Figure 1B, Online Video 2).
LV pseudoaneurysm is a rare but serious complication after TA-TAVR (1). Percutaneous pseudoaneurysm closure after TA-TAVR via a retrograde transfemoral approach was previously reported (2), but this technique has some concerns, including the long access route to the LV apex and potential risk of valve injury. By contrast, the antegrade transseptal approach provides an appropriate access route, allowing the usage of a standard delivery system for the occluder device, and eliminates the risk of damaging the implanted valve. Therefore, it is suggested that the present technique be considered as the first-line option for LV pseudoaneurysm closure after TA-TAVR.
For the supplemental videos, please see the online version of this article.
Dr. Makkar has received grant support from Edwards Lifesciences Corporation and St. Jude Medical. Dr. Kar is a consultant for St. Jude Medical; and has received grant support from St. Jude Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received May 19, 2014.
- Accepted May 22, 2014.
- American College of Cardiology Foundation
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