Author + information
- Received March 23, 2015
- Accepted April 9, 2015
- Published online August 17, 2015.
- ∗Division of Cardiovascular Diseases, Department of Medicine, University of Rochester, Rochester, New York
- †Department of Radiology, University of Rochester, Rochester, New York
- ↵∗Reprint requests and correspondence:
Dr. Mohamad Alkhouli, Division of Cardiovascular Diseases, University of Rochester, 601 Elmwood Avenue, Box 679C, Rochester, New York 14642-8679.
- Amplatzer vascular plug
- cardiac computed tomography
- percutaneous closure
- right ventricular pseudoaneurysm
Ventricular pseudoaneurysm is a contained rupture of the ventricular wall that may occur after myocardial infarction, trauma, infection, transcatheter valve replacement, or cardiac surgery (1–4). It usually occurs in the left ventricle, with very few reports of right ventricular (RV) pseudoaneurysm (3). Left untreated, this serious complication is associated with a 40% incidence of rupture at 1 year (1). Surgical repair is generally considered the standard treatment, but is associated with high morbidity and mortality (2). Percutaneous pseudoaneurysm closure has emerged as a new alternative for high-risk surgical patients. This technique has been described in small case series of patients with left ventricular pseudoaneurysm (1,3,4). We describe a case of an acquired RV pseudoaneurysm following pericardiocentesis, which was successfully treated with percutaneous closure.
A 71-year-old man with hypertension, diabetes, atrial fibrillation, morbid obesity, and oxygen-dependent obstructive pulmonary disease presented with worsening dyspnea and was found to have a large pericardial tamponade. Pericardiocentesis was attempted via the apical route under ultrasound guidance, but images were very limited by body habitus. The attempt was complicated with RV puncture, severe tamponade and shock requiring intubation, and emergent pericardial window. Two days later, an abdominal computed tomography was done after an episode of hematemesis and incidentally revealed an RV pseudoaneurysm. This was further confirmed on transthoracic echocardiogram (Online Video 1). He was at an excessive risk for open repair, and was therefore referred for a percutaneous closure of the pseudoaneurysm. A planning cardiac computed tomography revealed a pseudoaneurysm sac size of 3.6 × 3.2 cm, and a tortuous neck that measured 15.3 × 7.9 mm in diameter and 5.1 to 7.2 mm in length (Figures 1 and 2, Online Videos 1 and 2).
Right ventriculography was performed revealing the RV pseudoaneurysm (Figure 3A, Online Videos 3 and 4). The position of the RV pseudoaneurysm relative to the chest wall was confirmed with angiography and transthoracic echocardiography. An intracardiac-echo catheter was positioned in the RV for further guidance, but was technically limited. The pseudoaneurysm sac was entered with a micropuncture needle and a 0.014-inch Choice PT Extra-Support wire (Boston Scientific, Marlborough, Massachusetts) was manipulated across the pseudoaneurysm neck into the right atrium. The tract was dilated with a 5-F micropuncture dilator and a 4-F sheath was advanced into the pseudoaneurysm. A 4-F angled glide catheter (Terumo, Tokyo, Japan) was then advanced into the inferior vena cava to allow exchange for a 0.035-inch Amplatz Extra-Support wire (Boston Scientific). The 4-F sheath was then exchanged for an 8-F BRITE TIP sheath (Cordis, Bridgewater, New Jersey), which was advanced into the right atrium. A 0.018-inch SV-5 wire (Cordis) was advanced alongside the Amplatz Extra-Stiff wire into the superior vena cava for support during device deployment and to act as a safety wire. The Amplatz Extra-Stiff wire was removed and the sheath was retracted into the RV. A 16-mm Amplatzer Vascular Plug II device (AGA Medical, Golden Valley, Minnesota) was deployed across the defect using RV injections for guidance (Online Videos 4 and 5). Repeat RV angiography showed no significant flow into the pseudoaneurysm sac (Online Video 6). With the sheath’s tip still in the pseudoaneurysm, thrombin was injected into the sac to ensure complete thrombosis of the sac (Figure 3B, Online Videos 5, 6, and 7). The sheath was then removed and the chest wall tissue tract was filled with Tisseal fibrin sealant (Baxter, Deerfield, Illinois). A repeat echocardiogram showed complete cessation of flow into the pseudoaneurysm sac (Online Video 7), and the patient was discharged to a rehab facility 1 week later.
For accompanying videos, please see the online version of this article.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received March 23, 2015.
- Accepted April 9, 2015.
- 2015 American College of Cardiology Foundation
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