Left Ventricular Repair
A novel percutaneous technique allows for a minimally invasive therapeutic option to treat a left ventricular pseudoaneurysm.
A 70-year-old, white woman was admitted 6 weeks after coronary artery bypass surgery and aortic valve replacement with a St. Jude 19-mm prosthetic valve (St. Jude Medical, St. Paul, MN). She presented with diaphoresis, chest pain radiating to both shoulders and her sternal area, and shortness of breath that was partially relieved by nitroglycerin and morphine. Her medical history was significant for previous bilateral upper lobectomy for COPD and stage I primary lung carcinoma, HTN, hyperlipidemia, and anemia. Her blood pressure was 110/56 mm Hg, her pulse was 90/min, and her respiration was 18/min. She was anemic (Hgb 8.3 mg/dL), had heme-positive stools, was hypokalemic (2.9 mg/dL), and had borderline initial cardiac iso-enzymes. Electrocardiography revealed nonspecific changes, whereas portable chest x-ray demonstrated a widened mediastinum with tracheal rotation and elevation.
HOW WOULD YOU PROCEED?
1. After stabilization, what further diagnostic studies would you order?
2. Would you take the patient to the cardiac catheterization laboratory or to the operating room after further diagnostic studies were completed?
CT was performed with and without intravenous contrast. Noncontrast images demonstrated a large, soft tissue mass elevating and displacing the heart while depressing the diaphragm. Reconstructed coronal and sagittal images with intravenous contrast demonstrated a large, left ventricular pseudoaneurysm with the narrow neck emanating from the left ventricular apex extending inferiorly and laterally (Figure 1). Transesophageal echocardiography, with the aid of color Doppler, confirmed the diagnosis of left ventricular pseudoaneursym after a high-velocity jet with continuous flow was identified at the left ventricular apex extending into the aneurysmal cavity. The ventricular pseudoaneurysm was constrained by the residual pericardial sac. Much lower Doppler signals were noted remotely in the inferolateral pseudoaneurysm. The fistula occurred at the site of a failed pledget after ventricular apical venting of air following aortic valve replacement, coronary artery bypass, and cardiopulmonary bypass.1 Aspiration was performed in this location because of previous bilateral upper-lobe resection.
COURSE OF ACTION
The patient was taken to the cardiac catheterization laboratory for diagnostic right and left heart catheterization. Right heart catheterization demonstrated minimally elevated right heart pressures. Transseptal technique revealed normal left ventricular systolic function with moderate left ventricular noncompliance. The left ventricular ejection fraction was 75%. Left ventriculography was then performed in the LAO and RAO projections to further define the lesion (Figure 2A,B).
Given the high risk of surgical mortality and prolonged intubation with likely pulmonary complications, the patient was placed under conscious sedation in the cardiac catheterization suite. Intravenous cefazolin (1 g) was administered prophylactically. A right common femoral vein 8-F sheath was established and exchanged for a Daig Fast Cath (Daig Corporation, Minnetonka, MN) transseptal sheath, which was advanced to the superior vena cava. Catheterization was then performed using a standard Brockenbrough needle and transseptal technique. After the needle was noted to cross the septum, as determined by hemodynamic monitoring, a Platinum Plus (Boston Scientific Corporation, Natick, MA) coronary guidewire was advanced through the septal sheath and the mitral valve and into the ventricular apex.
Using a 6-F SciMed (Boston Scientific Corporation) pigtail catheter, left ventriculography was repeated to confirm continued presence of the left ventricular apex pseudoaneurysm. The coronary guidewire was then advanced through the mouth of the pseudoaneurysm using a 5-F Glidecath (Terumo, Somerset, NJ). The Glidecath was then exchanged with a Swan-Ganz (USCI/Bard, Billerica, MA) catheter, which was advanced over the wire through the ventricular wall into the pseudoaneurysm. The Swan-Ganz balloon was then inflated with approximately 1.5 mL of diluted contrast. Next, the Swan-Ganz balloon was gently retracted to occlude the orifice of the pseudoaneurysm (Figure 3).
Once this mechanical tamponade was stabilized at the pericardial surface of the ventricular apex, a Target Turbo Tracker (Boston Scientific Corporation) system was advanced over the wire through the lumen of the Swan-Ganz catheter into the pseudoaneursym. Multiple Target helical coils and Tornado microcoils (Cook Incorporated, Bloomington, IN) were then deployed into the pseudoaneurysm (Figure 4). Follow-up injection through the microcatheter demonstrated persistent flow related to the jet effect from the left ventricle. Because of persistent flow in the pseudoaneurysm, 3 mL of reconstituted Topical Thrombin 5,000 units (King Pharmaceuticals, Inc., Bristol, TN) was injected into the cavity.
To provide a stable nest of coils at the mouth of the pseudoaneurysm, the microcatheter was directed around the circumference of the Swan-Ganz several times, forming a circle under fluoroscopy. Repeat embolization was then performed with multiple coils as the Swan-Ganz balloon was slowly deflated over 15 minutes. After the Swan-Ganz catheter was removed from the pseudoaneurysm, ventriculography was performed in both LAO and RAO projections (Figure 5). No residual filling of the pseudoanuerysm was noted, and residual contrast from previous dedicated microcatheter injections within the pseudoaneurysm was still visible. The venous sheath was removed and the patient was transferred to the telemetry ward for observation.
The patient remained stable overnight, and follow-up echocardiography confirmed thrombosis of the left ventricular pseudoaneurysm. An enhanced CT scan performed the following day demonstrated no contrast perforating the ventricular wall and only residual contrast in the thrombosed pseudoaneurysm from the previous embolization. A 3-month follow-up CT scan of the thorax demonstrated complete reabsorption of the thrombosed pseudoaneurysm and residual contrast within the sac (Figure 6A,B). Embolization coils remained localized to the pericardial sac.
Left ventricular pseudoaneurysms are extremely rare.2 When they do occur, they are typically related to myocardial infarction or are posttraumatic.3 The ventricular pseudoaneurysm occurs when a rupture of the ventricular free wall is contained by overlying, adherent pericardium.4 Ventricular free wall rupture occurs in most cases of cardiac rupture and is usually associated with sudden cardiac death because of hemopericardium and subsequent cardiac tamponade.5 Surgical resection is recommended prior to severe left ventricular distention and decompensation. The usual treatment for left-ventricular pseudoaneurysm is urgent surgical resection with possible linear closure, patch, or flap repair.6
This case involves an iatrogenic pseudoaneurysm that developed from a failed suture pledget at the left ventricular apical ventilation site. A search of the literature leads us to believe this is the first known case in which percutaneous endovascular techniques were utilized to treat a ventricular pseudoaneurysm. The transseptal route is also unique in this case in that care was taken to avoid traversing the new St. Jude prosthetic aortic valve. Exclusion of the pseudoaneurysm was necessary because of the inherent risk of rupture and likely death. Surgery was considered, but the likelihood of a perioperative death related to cardiopulmonary collapse was believed to be very high. The patient could not be maintained on anticoagulants other than antiplatelet agents because of the history of chronic gastrointestinal bleeding. The Swan-Ganz balloon was the critical element in the treatment regimen. The device was used in an inverse analogous fashion to the Foley balloon being used in the trauma setting of a penetrating injury. It stabilized the left ventricular apex, controlled the velocity vortices at the neck of the pseudoaneurysm, and provided a conduit for embolization via coils and thrombin injection. The Swan-Ganz balloon also prevented embolization to the left heart and systemic circulation. It also provided a controlled dynamic setting where, as the balloon was deflated over time, the coil nest at the neck was packed even more tightly in a circumferential fashion around the balloon.
Endovascular techniques continue to provide a platform for treating increasingly challenging cases in which the risks for surgical correction are unacceptable. Embolization provided the minimally invasive therapeutic option to treat this left ventricular pseudoaneurysm.
James F. McGuckin, MD, is the Medical Director of the Philadelphia Vascular Institute, Philadelphia; Section Head of Interventional Radiology at Elkins Park Hospital, Elkins Park; and Director of Interventional Radiology at The Graduate Hospital, Philadelphia, Pennsylvania. He holds no financial interest in any product or manufacturer mentioned herein. Dr. McGuckin can be reached at (215) 742-5662; firstname.lastname@example.org.
Richard C. Kovach, MD, is the Director of the Cardiac Catheterization Laboratory at Our Lady of Lourdes Medical Center, Camden, New Jersey. He holds no financial interest in any product or manufacturer mentioned herein. Dr. Kovach may be reached at (856) 757-3500.
Reginald J. Blaber, MD, is from the Cardiology Department at Our Lady of Lourdes Medical Center, Camden, New Jersey. He holds no financial interest in any product or manufacturer mentioned herein. Dr. Blaber may be reached at (856) 757-3500.
Joseph P. Curreri, MD, is from the Pulmonary Department at Our Lady of Lourdes Medical Center, Camden, New Jersey. He holds no financial interest in any product or manufacturer mentioned herein. Dr. Curreri may be reached at (856) 757-3500.
John A. Heim, MD, is from the Thoracic Surgery Department at Our Lady of Lourdes Medical Center, Camden, New Jersey. He holds no financial interest in any product or manufacturer mentioned herein. Dr. Heim may be reached at (856) 757-3500.
1. Kao CL, Chang JP. Left ventricle pseudoaneurysm secondary to left ventricle apical venting. Texas Heart Inst J. 2003;30:162-163.
2. Rao MS, Vaijyanath P. Recurrent pseudoaneurysm of the left ventricle with subcutaneous herniation into the chest wall. Texas Heart Inst J. 1998:25:309-311.
3. Maselli D, Micalizzi E. Post-traumatic left ventricular pseudoaneurysm due to intramyocardial dissecting hematoma. Ann Thorac Surg. 1997;64:830-831.
4. Brown SL, Gropler RJ. Distinguishing left ventricular aneurysm from pseudoaneurysm: a review of the literature. Chest. 1997;111:1403-1409.
5. Hung MJ, Wang CH. Unruptured left ventricular pseudoaneurysm following myocardial infarction. Heart. 1998;80:94-97.
6. Mickleborough LL. Surgical management of left ventricular aneurysms. Semin Thorac Cardiovasc Surg. 1995;7:233-239.