Transapical Implantation of Edwards Sapien XT Valve to Close a Left Ventricular Outflow Tract Pseudoaneurysm

Abstract

A 58-year-old man presented with symptomatic high-degree atrioventricular block and congestive heart failure. His medical history included a bicuspid aortic valve (AV), aortic stenosis, and 3 bioprosthetic AV replacement operations-the last, 25 years before, to place a homograft. At the current admission, the patient underwent pacemaker implantation to treat the heart block. Then, a structural AV abnormality was detected. A transesophageal echocardiogram (TEE) showed paravalvular leak and a new finding: a 1.5 × 1.7-cm pseudoaneurysm at the base of the aortic root, adjacent to the fibrous trigone. The pseudoaneurysm, connected by a tract to the left ventricular outflow tract (LVOT), bulged into the left atrium and exhibited pulsatile expansion during systole (Fig. 1). A computed tomographic angiogram showed a 1.8 × 1.9-cm focal outpouching, inferior to the takeoff of the left main coronary artery and posterior to the aortic root. A 3-to 4-mm connection was identified at the 6 o'clock position with respect to the LVOT. The patient's heart failure was probably related to the structural defect. To avoid repeat sternotomy, we chose a percutaneous closure approach. Under diagnostic fluoroscopy (Fig. 2) and intraprocedural TEE (Fig. 3), the pulsatile defect was evident.

Percutaneous closure of left ventricular pseudoaneurysm

“…The percutaneous closure of LVPA was performed on an urgent basis in 3 (3.2%) patients [13,20,23]. The percutaneous procedures succeeded on the first try in 79 (84.9%) patients, whereas failures were encountered during the percutaneous manoeuvres in 14 (15.1%) patients [10,11,14,24,30,44,51,54,[63][64][65][66][67]70]. Of the latter 14 patients, the percutaneous closure of LVPA eventually succeeded in 12 (85.7%) patients, whereas it had to convert to open surgery in 2 (14.3%) patients [66,67].…”

“…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).…”

“…Minimal residual flow immediate after closure could be observed in 13 patients [ 5 , 20 , 29 , 39 , 43 , 48 , 49 , 54 , 57 , 60 , 65 , 68 , 71 ], and on day 2 in 2 patients [ 66 , 67 ]. No flow was observed 41 patients 16.7 ±37.8 (range: 0–180; median: 0) days after closure [ 5 , 7 , 9 , 13 , 14 , 16 – 22 , 24 – 29 , 31 , 33 , 38 , 41 – 44 , 46 – 49 , 51 , 55 – 58 , 60 , 61 , 65 , 66 , 68 , 70 ].…”

“…Amplatz Vascular Plug II [9, 11, Advances in Interventional Cardiology 2022; 18, 2 (68) [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]. Minimal residual flow immediate after closure could be observed in 13 patients [5,20,29,39,43,48,49,54,57,60,65,68,71], and on day 2 in 2 patients [66,67]. No flow was observed 41 patients 16.7 ±37.8 (range: 0-180; median: 0) days after closure [5, 7, 9, 13, 14, 16-22, 24-29, 31, 33, 38, 41-44, 46-49, 51, 55-58, 60, 61, 65, 66, 68, 70].…”

Native Aortic Valve Endocarditis Complicated by Splenic Infarction and Giant Mitral-Aortic Intervalvular Fibrosa Pseudoaneurysm—A Case Report and Brief Review of the Literature

“…Published papers have described aortic valve replacement alone or combined with individualized reconstruction procedures (i.e., simple aneurysmal suture or reinforced with various materials, homograft aortic root replacement, and coronary artery bypass grafting) as of current open-surgery options [13][14][15]. Few authors have described successful percutaneous device-therapy of P-MAIVF using various devices (coil embolization, septal occluder devices, vascular plugs, transapical implantation of an Edwards Sapien XT valve-in-valve fashion) as an alternative when surgery is not appropriate [32][33][34]. Recently, Boi et al reported the first successfully exclusion of a P-MAIVF by transapical transcatheter implantation of a balloon-expandable Edwards Sapien 3 Ultra valve in a 78-year-old man with concomitant severe aortic stenosis [35].…”