Sample Interventional Challenging Case: Percutaneous Closure of a Left Ventricle Apical Pseudoaneurysm After Transapical Transcatheter Aortic Valve Replacement

Author: Michael K. Amponsah, Rajiv Verma, Marc Cohen, Mihir Barvalia, Yassir Nawaz, Nishant Sethi, Ahmed Seliem, Mark Russo, Newark Beth Israel Medical Center, Newark, NJ, USA

Case Submission:

  • Initials: AL
  • History: An 83-year-old female with past medical history of coronary artery disease status-post coronary artery bypass grafting with a patent left internal mammary artery to left anterior descending artery 5 years prior, aortic stenosis and severe mitral regurgitation presented to our facility with complaint of worsening exertional dyspnea. She subsequently underwent transapical transcatheter aortic valve replacement (TA-TAVR) and concurrent percutaneous coronary intervention (PCI) of distal left main and proximal ramus. She was discharged in improved condition on dual antiplatelet therapy because of PCI. She presented again to our facility 4 weeks post-TAVR due to worsening dyspnea.
  • Physical Exam: Alert and fully oriented. Precordium: S1, S2. Grade II systolic ejection murmur best heard at right upper sternal border. Lungs: Mild rales at base of left lung. Extremities: No edema.
  • Test Results Prior to Catheterization: Cardiac Computed Tomography - Left Ventricle (LV) apical pseudoaneurysm with a neck size of 11 mm x 14 mm and largest diameter of 59.6 mm. Transesophageal Echocardiogram - LV apical pseudoaneurysm and a moderate sized anteriorly located pericardial effusion.
  • Interventional Management: Successful percutaneous closure of LV pseudoaneurysm was performed with an Amplatzer Muscular Ventricular Septal Occluder through direct percutaneous access of the LV apical pseudoaneurysm. She was discharged 1 week post-procedure in improved condition.

Case Description: Left ventricle (LV) apical pseudoaneurysm is an infrequent complication of Transapical Transcatheter Aortic Valve Replacement (TA-TAVR). We describe a case of an 83-year-old female who underwent TA-TAVR after presenting with severe symptomatic aortic stenosis. She was re-admitted four weeks post-TAVR with worsening dyspnea. Cardiac computed tomography, echocardiography and cardiac catheterization left ventriculography findings were consistent with LV apical pseudoaneurysm. She was deemed high risk for surgical repair and the decision was made to attempt a percutaneous closure of the LV apical pseudoaneurysm. Under echocardiographic and fluoroscopic guidance, an Amplatzer Muscular Ventricular Septal Occluder was successfully deployed through direct percutaneous access of the pseudoaneurysm. Patient was discharged 1 week post-procedure in improved condition.

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