Author + information
- Received March 7, 2016
- Revision received April 18, 2016
- Accepted April 21, 2016
- Published online July 11, 2016.
- Jason Foerst, MD∗ ()
- ↵∗Reprint requests and correspondence:
Dr. Jason Foerst, Virginia Tech Carilion School of Medicine, 2001 Crystal Springs Avenue, Roanoke, Virginia 24014.
A 74-year-old woman with severe aortic regurgitation, moderate mitral regurgitation, coronary artery disease status post bypass with left internal mammary artery to the left anterior descending coronary artery, and severe emphysema was deemed inoperable for open aortic valve replacement and underwent elective transcatheter aortic valve replacement. Because of the lack of annular calcium, the recapturable 29-mm Evolut R (Medtronic, Minneapolis, Minnesota) was chosen. We had considerable difficulty landing the valve because of movement from the aortic regurgitation without calcium in the annulus. After release, the valve migrated considerably into the left ventricle, with a mild residual paravalvular leak (Figure 1). The follow-up echocardiogram was notable for a new left ventricular apical perforation with pseudoaneurysm (PSA) (Figure 2A). The perforation was presumed to be from the motion of the delivery system delivered over a shaped Lunderquist wire (Cook Medical, Bloomington, Indiana). The PSA enlarged over the following 2 days, so given the patient’s prohibitive surgical risk, we decided to treat percutaneously. An 8-F Torqueview guide (St. Jude Medical, Minneapolis, Minnesota) was advanced to the left ventricle over a J wire that was directed into the left ventricular PSA. An injection was performed demonstrating the neck of the PSA. A 5-F multipurpose catheter was advanced through the Torqueview over the J wire into the PSA, and the delivery catheter was advanced over the multipurpose catheter. The multipurpose catheter and wire were removed, and a 10-mm Amplatzer muscular ventricular septal defect occluder (St. Jude Medical, Minneapolis, Minnesota) was deployed. There was a trivial residual leak. At 4-month follow-up, the patient’s dyspnea was improved and the PSA space stable, with a small residual color jet on echocardiography (Figure 2).
There are several reports of closure devices being used for left ventricular PSA following myocardial infarction and failed transapical closures, but this is the first report of repair of wire perforation following transcatheter aortic valve replacement (1,2).
Dr. Foerst is a consultant for Medtronic; and a member of the Speakers Bureaus for Edwards Lifesciences and St. Jude Medical.
- Received March 7, 2016.
- Revision received April 18, 2016.
- Accepted April 21, 2016.
- American College of Cardiology Foundation
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