Complete Percutaneous Obliteration of a Post-Infarction Left Ventricular Inferior Wall Pseudoaneurysm

Abstract

A 67-year-old woman, with a history of inferior wall myocardial infarction, presented at a general hospital with a 4-week history of sudden onset heart failure in New York Heart Association functional class III. Echocardiography revealed inferior wall pseudoaneurysm formation, probably because of recent myocardial infarction (Fig. 1A). Because the patient refused the proposal of immediate surgical treatment, we planned a percutaneous procedure. Coronary angiography revealed occlusion of the peripheral segment of the right coronary artery, multilevel critical stenoses in the left anteFigure 1. Inferior Wall Pseudoaneurysm Formation (A) Echocardiography (apical 2-chamber view): inferior wall pseudoaneurysm cavity. (B) Left ventriculography view: rupture in the left ventricular inferior wall and opacification of pseudoaneurysm cavity. (C) Multislice computed tomography reconstruction: for optimal visualization of pseudoaneurysm cavity, the right ventricle was removed. (D) Left ventricle and pseudoaneurysm cavity-largest dimension cross-section: noticeably thinned myocardium within post-infarction necrotic tissue in the region of inferior wall and myocardial discontinuity visible. Posteromedial papillary muscle is localized superior to the pseudoaneurysm orifice. *Pseudoaneurysm cavity.

Successful percutaneous closure of post myocardial infarction left ventricular ruptured pseudoaneurysm after failed surgical repair

“…Recently there has been some published experience regarding percutaneous closure of LV pseudoaneurysm as an alternative to surgical repair in patients at high operative risk [12,13]. This is a rare case because the pseudoaneurysm rupture did not lead to pericardial tamponade which could be explained by pericardial space obliteration as a consequence of her previous surgery.…”

Percutaneous closure of left ventricular pseudoaneurysm

“…In 14 patients there were one or more associated disorders, which totalled 18 (Table IV). Concurrent procedures were performed in 10 (10.8%) patients: left ventricular apical puncture sealed with another occluder in 2 (25%) [18,62], coronary artery stenting in 2 (25%) [56,61], inferior vena cava stenting [14], a 2 nd 4-mm ASO deployed across the apical puncture [18], true aneurysm closure with a 10 mm Amplatzer Vascular Plug II [38], coronary artery thrombus aspiration and extracorporeal membrane oxygenation [53], transcatheter mitral valve implant with a 23-mm Edwards Sapien 3 [21], and onestage simultaneous endovascular repair for abdominal aortic aneurysm and LVPA [67] in 1 patient, each. The three-dimensional sizes of the LVPAs were 47.7 ±27.4 (range: 7-130; median: 40) mm (n = 61), 38.1 ±20.4 (range: 8.6-90; median: 34.5) mm (n = 50), and 30.7 ±18.4 (range: 10-90; median: 29.5) mm (n = 18).…”

“…The 66 recruited articles included 1 (1.5%) retrospective study [ 22 ], 4 (6.1%) case series [ 36 , 48 , 52 , 65 ], 43 (65.2%) case reports [ 5 , 7 , 9 – 11 , 13 , 14 , 17 – 21 , 24 , 25 , 27 – 32 , 34 , 35 , 38 – 40 , 42 , 43 , 45 – 47 , 49 – 51 , 54 , 55 , 58 , 60 , 62 , 63 , 66 – 68 , 71 ], 14 (21.2%) medical images [ 12 , 15 , 16 , 23 , 26 , 33 , 41 , 44 , 53 , 56 , 59 , 61 , 69 , 70 ], and 4 (6.1%) proceeding abstracts/posters [ 8 , 37 , 57 , 64 ]. There were a total of 93 patients, including 58 (63.0%) male and 34 (37.0%) female (χ 2 = 12.5, p = 0.001), with a male-to-female ratio of 1.7 : 1 (gender of 1 patient was unknown).…”

“…Effects of percutaneous closure for LVPA cavity were reported as follows: complete exclusion of the LVPA ( n = 8) [ 7 , 12 , 15 , 28 , 33 , 44 , 45 , 50 ], complete thrombosis of LVPA with no residual flow ( n = 7) [ 11 , 26 , 34 , 41 , 46 , 55 , 61 ], contraction of the pseudoaneurysm ( n = 1) [ 69 ], partial thrombosis of LVPA ( n = 1) [ 7 ], no blood communication to LVPA by thrombin injection [ 51 , 37 ], large LVPA sacs filled with embolisation coils ( n = 3) [ 37 ], LVPV reduced in diameter [ 6 ], and LVPA persistent but not increasing in size and partially thrombosed [ 39 ].…”

“…Effects of percutaneous closure for LVPA cavity were reported as follows: complete exclusion of the LVPA (n = 8) [7,12,15,28,33,44,45,50], complete thrombosis of LVPA with no residual flow (n = 7) [11,26,34,41,46,55,61], contraction of the pseudoaneurysm (n = 1)…”