Transcatheter Closure of Left Ventricular Pseudoaneurysm

ABSTRACT: Left ventricular pseudoaneurysm is a rare complication of myocardial infarction, cardiovascular surgery, trauma, or infection. Untreated left ventricular pseudoaneurysm can have significant morbidity and mortality. Surgical treatment has generally been the standard of care. However, with a sicker and older population, surgical risks can sometimes be significant. We report a case of successful percutaneous closure of left ventricular pseudoaneurysm using coils and a vascular plug. We emphasize the role and importance of multimodality imaging for accurate diagnosis and therapy, and briefly review the literature on the various approaches used for percutaneous closure of left ventricular pseudoaneurysms.

J INVASIVE CARDIOL 2012;24(6):E111-E114

Key words: cardiac rupture, pseudoaneurysm, percutaneous pseudoaneurysm repair

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Left ventricular (LV) pseudoaneurysms occur when cardiac rupture is contained by pericardium. Myocardial infarction is the most common cause, followed by cardiovascular surgery, trauma, and infection.¹ Post-myocardial infarction (MI) pseudoaneurysms are most commonly located in the inferior or posterolateral walls. Post-surgical pseudoaneurysms are located in posterior subannular region after mitral valve surgery, subaortic region after aortic valve surgery, and the right ventricular outflow tract after congenital heart surgery.^2,3 The incidence of post-MI pseudoaneurysm may be declining because of aggressive early treatment of ST-elevation MIs. Nonetheless, once a pseudoaneurysm has developed, serious complications such as angina, heart failure arrhythmias, thrombus with embolization, and fatal rupture can occur.⁴  

Pseudoaneurysms can expand and lead to full rupture, and the untreated mortality in the largest series was 48%.¹ Acute and symptomatic pseudoaneurysms have a higher risk of fatal rupture, and there have been small reports of chronic, incidentally discovered pseudoaneurysms with a more benign prognosis.^5,6 However, because surgical mortality is now less than 10%, surgery is the preferred treatment.⁷ In some patients with multiple co-morbidities, surgical risk can be significant, and the management of these patients is difficult. We report a case of percutaneous closure of an LV pseudoaneurysm with coils and a vascular plug, and review the literature on percutaneous strategies for the management of LV pseudoaneurysms.

Case Report. A 49-year-old female patient presented with a history of coronary artery disease with coronary artery bypass surgery, morbid obesity status post gastric bypass surgery, chronic obstructive pulmonary disease, diabetes mellitus, and chronic MRSA wound infections, abscesses, and poor wound healing. Approximately 1 month prior to clinical presentation, she started having worsening dyspnea, chest pain, and was essentially bedridden. Workup revealed patent bypass grafts and normal pressures on right heart catheterization. Chest CT showed a poorly defined aneurysm in the left side of the heart. Transthoracic and transesophageal echocardiograms revealed a 5 cm LV pseudoaneurysm (Figures 1 and 2). Cardiac MRI showed a 4.2 x 4.3 x 5.8 cm cavitary lesion adjacent to the posterolateral wall of the left ventricle and a small tract from the LV cavity to the cavity (Figure 3). Flow turbulence was noted across this tract. She was referred to cardiothoracic surgery for surgical repair of the pseudoaneurysm. Given the patient’s comorbidities including significant recurrent problems with wound healing, and after careful discussions of risks, benefits, and alternatives, we referred the patient for percutaneous closure of the pseudoaneurysm.

The patient was intubated and the procedure was performed under transesophageal echocardiography (TEE) guidance. The TEE showed a large LV pseudoaneurysm in the posterior aspect of the base of the left ventricle just below the mitral annulus. The neck of the aneurysm was 6 mm and the aneurysm size was 5.1 x 4.4 cm. A 7 Fr AL-2 guide catheter was used to engage the pseudoaneurysm (Figure 4) and a 0.035-in glidewire was advanced into it. A 5 Fr hypotube was advanced over the glidewire into the aneurysm cavity and the glidewire was removed. Eighteen embolization coils of different lengths were advanced into the aneurysm cavity. The neck of the pseudoaneurysm was occluded using a 12 mm AGA Amplatzer II vascular plug. There was no communication between the LV cavity and pseudoaneurysm cavity after the plug was deployed (Figure 5).

The patient did well after the procedure. She did not have further chest pain or dyspnea. She reported significantly increased exercise capacity. Cultures from the pseudoaneurysm cavity were negative. Follow-up echocardiogram 1 month later showed no communication between the left ventricle and previously closed pseudoaneurysm (Figures 6 and 7).

Discussion. LV pseudoaneurysms are uncommon but can lead to significant morbidity and mortality.  They have been reported with MI, cardiovascular surgery, trauma, and infection.  They have also been reported late after treatment of endocarditis.⁸ Ring abscesses that communicate with the LV cavity and expand over time can form pseudoaneurysms.⁹ Given our patient’s history of recurrent staphylococcal bacteremia, this could have been a predisposing cause.

Diagnosis can be made noninvasively or invasively. Transthoracic echocardiography, while not always diagnostic, is simple and provides important information about the pseudoaneurysm as well as other potential structural problems. However, nonstandard views may be required and cavity underestimation can occur because of thrombus.^10,11 Angiography has been the gold standard for diagnosis, but cardiac MRI is increasingly being used to provide detailed information about the location, size, relationship to adjacent structures, and to differentiate aneurysms from pseudoaneurysms.^12,13 Cardiac CT and TEE can be used in the diagnosis of pseudoaneurysm, but there is limited experience with these modalities.    

Surgical repair has traditionally been the treatment of choice. This is usually achieved with resection of the false aneurysm and either primary closure of the defect or patch closure.¹⁴ Surgical mortality has now improved to less than 10%, and long-term outcomes are favorable, with durable repair and NYHA I-II symptoms.^15,16 However, with a generally older population with multiple comorbidities, the risk of surgical morbidity remains high in subsets of patients. In recent years, there have been rapid advances in the percutaneous management of atrial and ventricular septal defects and congenital abnormalities as patent ductus arteriosus, as well as development of a variety of vascular closure plugs and closure devices. There is limited experience with these catheter-based devices in the management of LV pseudoaneurysms in the high-risk surgical candidate.

The first case report of nonsurgical treatment of LV free wall rupture was injection of fibrin glue into the pericardium after pericardiocentesis in an elderly woman with cardiac tamponade after acute MI, with good outcome.¹⁷ Since then, several individual case reports have described successful use of Amplatzer septal occluders, VSD occluders, and coils.^18-25 A successful transseptal approach to LV pseudoaneurysm closure in a patient with mechanical aortic valve has been described.²⁶ Urgent transcatheter closure after iatrogenic LV free wall rupture during attempted VSD repair, as well as after LV perforation during endomyocardial biopsy have been successful.^27,28 Vascular plug use has been less frequent,²⁹ and there is a report of successful use of angioseal femoral closure device for RV perforation.³⁰ We describe the use of coils to embolize a large pseudoaneurysm cavity followed by a vascular plug device to close the neck of the pseudoaneurysm. Coils were used because of the large pseudoaneurysm cavity, uncertainty about the integrity of tissue around the vascular plug, and concerns of plug migration or embolization. Embolization of the pseudoaneurysm cavity with coils may have provided more stability for the vascular plug. This technique provided excellent results and good intermediate-term results in our patient.

Given the infrequency of LV pseudoaneurysms and short clinical experience with percutaneous devices, there has been limited clinical experience with a variety of percutaneous closure devices for pseudoaneurysm repair. There are no large studies to guide optimal device selection, which needs to be individualized given the location, size, and structures adjacent to the pseudoaneurysm. The use of multimodality imaging, including periprocedural angiography and transesophageal or intracardiac echo, and preoperative assessment with transthoracic echo or MRI is important in appropriate device selection. Outcomes relative to surgery are not available yet. Operator experience and volume are important factors, but given the rarity of this condition, even large referral centers have limited experience. However, limited data suggest that percutaneous LV pseudoaneurysm repair may be a good option for patients with high surgical risk.

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From the Section of Cardiovascular Diseases, University of Alabama at Birmingham, Birmingham, Alabama.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
Manuscript submitted October 12, 2011, provisional acceptance given December 20, 2011, final version accepted January 2, 2012.
Address for correspondence: Deepak Acharya, MD, THT 321, 701 19th Street South, Birmingham, AL 35294. Email: dacharya@cardiology.uab.edu