Transcatheter device closure of pseudoaneurysms of the left ventricular wall: An emerging therapeutic option

Incidental diagnosis of a large left ventricular pseudoaneurysm

Left ventricular pseudoaneurysm is a rare complication of myocardial infarction and represent a myocardial rupture contained within a pericardial space limited by adhesions. Differentiating it from a left ventricular aneurysm can be a real diagnostic challenge. We report a case of a 50-year-old man admitted for symptoms of left heart failure. Transthoracic echocardiography and cardiac computed tomography scan incidentally showed a large lateral left ventricular pseudoaneurysm measuring 75/50 mm in diameter. Patch closure was carried out under cardiopulmonary bypass. Postoperative follow up was uneventful. This case demonstrates the increasing detection of «incidental» left ventricular pseudoaneurysm with more frequent use of multimodality imaging techniques including cardiac CT scan.

Ventricular Pseudoaneurysm and Free Wall Rupture After Acute Myocardial Infarction: JACC Focus Seminar 4/5

Postinfarction ventricular free-wall rupture is a rare mechanical complication, accounting for <0.01% to 0.02% of cases. As an often-catastrophic event, death typically ensues within minutes due to sudden massive hemopericardium resulting in cardiac tamponade. Early recognition is pivotal, and may allow for pericardial drainage and open surgical repair as the only emergent life-saving procedure. In cases of contained rupture with pseudo-aneurysm (PSA) formation, hospitalization with subsequent early surgical intervention is warranted. Not uncommonly, PSA may go unrecognized in asymptomatic patients and diagnosed late during subsequent cardiac imaging. In these patients, the unsettling risk of complete rupture demands early surgical repair. Novel developments, in the field of transcatheter-based therapies and multimodality imaging, have enabled percutaneous PSA repair as a feasible alternate strategy for patients at high or prohibitive surgical risk. Contemporary advancements in the diagnosis and treatment of postmyocardial infarction ventricular free-wall rupture and PSA are provided in this review.

Percutaneous closure of left ventricular pseudoaneurysm

The aim of the present study is to describe the indications, treatment effects, and patient outcomes of percutaneous management of left ventricular pseudoaneurysm (LVPA). The study materials were based on comprehensive literature retrieval since 2004. The mechanisms of LVPA formation can be divided into surgical, percutaneous, and medial disease related. Of the surgical mechanisms, coronary artery bypass grafting prevailed. The formation time was the longest in medical disease-related LVPAs up to 44.4 months. 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. Percutaneous closure of LVPA was especially indicated for patients carrying a high surgical risk. The iatrogenic traumas, such as left ventricular venting, should be avoided to prevent this complication. The preliminary cut-off valves of oversize 3.3 mm and oversize ratio 1.6 should be followed for reference for device choice.

Systematic review and meta-analysis of the mechanical complications of ischemic heart disease: papillary muscle rupture, left ventricle rupture and post-infarct ventricular septal defect

BACKGROUND

Improvements in revascularisation, including pharmacological, catheter-based and surgical, have resulted in improved outcomes for patients with acute myocardial infarction (AMI), leading to decreased frequency of mechanical complications. Improvements in both techniques and technology have permitted select patients to be managed with a purely percutaneous, transcatheter strategy. Through systematic review, this study aims to synthesise the collective experience of percutaneous treatment of the mechanical complications of ischaemic heart disease.

METHODS

The search strategy queried the electronic databases PubMed, Embase and the Cochrane Central Register of Controlled Trials, from 1 January 2000 to 31 December 2020. Studies highlighting the outcomes of patients receiving percutaneous treatment of post-myocardial infarction papillary muscle rupture (PMR), ventricular septal defect (VSD), left ventricular free wall rupture (FWR) and pseudoaneurysm (PA) were included. A qualitative review of studies was conducted for PMR, FWR and PA. A quantitative analysis was conducted for VSD.

RESULTS

Fifteen studies were included in the qualitative synthesis of the percutaneous management of PMR, 4 were included in the qualitative analysis of the percutaneous management of left ventricular FWR, 7 studies defined the outcomes of the percutaneous management of PA and 25 were included in the quantitative meta-analysis of the primary percutaneous management of post-MI VSD. For VSD, there were 43 failed procedures in 314 patients. The proportion of failed procedures was 15.9% and there were 174 deaths in 428 patients. 37.5% of patients experienced early mortality.

CONCLUSIONS

Although surgical techniques remain the gold standard, we have shown that percutaneous management may be a viable option in certain cases.

Percutaneous closure of a left ventricular pseudoaneurysm after transcatheter ventricular septal defect closure

Left ventricular pseudoaneurysm is very rare in children. Although surgery is conventional treatment, recently, percutaneous closure of pseudoaneurysms has been described. Here, we present the first case where a patient developed left ventricular pseudoaneurysm after percutaneous ventricular septal defect device closure and was treated by a second percutaneous method.