Percutaneous closure of a large peri-prosthetic left ventricular pseudoaneurysm in a high-risk surgical candidate.

A 71-year-old woman presented with increasingly severe congestive cardiac failure 6 months after dual aortic/mitral bioprosthetic valve replacement for severe rheumatic valvular heart disease. Echocardiography showed the presence of a large (7.6×3.6×7.0 cm) left ventricular pseudoaneurysm (LVPA) originating from a 1.1 cm lateral free-wall disruption adjacent to the mitral prosthesis (fig 1, panels A and C). Given the risk of rupture and sudden death, urgent surgical repair was sought; however, procedural risk was deemed prohibitive owing to patient comorbidities. A novel percutaneous approach was considered. Figure 1 Angiographic (A, B) and computed tomography multiplanar reconstructions (C, D) demonstrating the large, posterolateral left ventricular pseudoaneurysm (arrowheads) originating from a free-wall disruption adjacent to the mitral bioprosthesis (MV). In the ... Multidetector computed tomography demonstrated the feasibility of LVPA closure via a retrograde approach (video 1). Percutaneous closure was undertaken via femoral arterial access, using fluoroscopic and combined transoesophageal/transthoracic echocardiographic guidance. Once across the bioprosthetic aortic valve, a 9F-delivery catheter was passed “behind” the mitral prosthetic support struts and into the LVPA cavity. A 12 mm Amplatzer ventricular–septal occluder (AGA Medical Corporation, Golden Valley, Mn, USA) was delivered successfully, with short postprocedural hospitalisation and marked improvement in heart failure symptoms (fig 1, panels B and D; video 2). Mitral valve replacement is associated with significant morbidity and mortality, and late complications such as valve dehiscence and pseudoaneurysm are not uncommon. Although published series have confirmed the utility of percutaneous closure for paravalvular dehiscence,1 perivalvular free-wall rupture and LVPA formation has routinely required repeat surgery, with high mortality rates.2 Isolated cases of percutaneous LVPA closure have been reported previously; however, the technical complexity of periprosthetic LVPA has previously prevented such an approach. As far as we are aware, this is the first published report of successful closure of a large, periprosthetic LVPA in a high-risk surgical candidate.