Percutaneous Closure of Right Ventricular Pseudoaneurysm

Abstract

V entricular 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 oxygendependent 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 Â 3.2 cm, and a tortuous neck that measured 15.3 Â 7.9 mm in diameter and 5.1 to 7.2 mm in length (Figures 1 and 2, Online Videos 1, 2). Right ventriculography was performed revealing the RV pseudoaneurysm (Figure 3A, Online Videos 3, 4).FIGURE 1 3D CT Long-Axis View of RV Pseudoaneurysm Cardiac computed tomography (CT) 3-dimensional (3D) reconstruction showing the right ventricular (RV) pseudoaneurysm in long-axis view (arrow). See Online Videos 1 and 2. F ¼ foot; L ¼ left; LA ¼ left atrium; LV ¼ left ventricle; P ¼ posterior; R ¼ right; RV ¼ right ventricle.

Multimodality Imaging of Right Ventricular Pseudoaneurysm Caused by Blunt Chest Trauma

“…The exact incidence of cardiac contusion is not known but has been reported to be as high as 15% to 24% when using specific cardiac markers such as troponin I or T (1) . Ventricular pseudoaneurysm, which is a contained rupture of the ventricular wall (2) and covered by pericardium, clot, or adhesion (3) , is a very uncommon complication of blunt chest trauma (4) . Pseudoaneurysms usually occur on the left side, and descriptions of right ventricular pseudoaneurysms are limited to rare case reports (5) .…”

“…Pseudoaneurysms usually occur on the left side, and descriptions of right ventricular pseudoaneurysms are limited to rare case reports (5) . Pseudoaneurysm is connected to the ventricle by a small neck (2) . This is in contrast to a true ventricular aneurysm, which contains myocardium and has a wider neck at its junction with the ventricle.…”

Percutaneous Closure of a Traumatic Right Ventricular Pseudoaneurysm: A Novel Interventional Approach

“… 14 , 15 Innovative techniques such as percutaneous closure of an RV pseudoaneurysm are rare but have been described. 16 …”

“…Percutaneous treatment for left ventricular pseudoaneurysm in high-risk surgical candidates is a novel approach and has been limited to a few case series 14, 15. Innovative techniques such as percutaneous closure of an RV pseudoaneurysm are rare but have been described 16 …”

An Incidentally Detected Right Ventricular Pseudoaneurysm

“…As a result, the benefits of aggressive surgical intervention for asymptomatic right ventricular pseudoaneurysm remain a topic of debate. Though innovative techniques such as percutaneous closure of left and right-sided ventricular pseudoaneurysms are a possibility [18], course of action, particularly in high risk patients, should be personalized.…”