Abstract
Transcatheter aortic valve replacement (TAVR) represents a viable therapeutic option in patients with severe symptomatic aortic valve stenosis. The development of a left ventricular pseudoaneurysm (LVP) represents an infrequent but potentially catastrophic complication after transapical TAVR. In this case report, we present a patient undergoing TAVR through subclavian access which had an LVP and underwent successful percutaneous closure.
Highlights
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Transcatheter aortic valve replacement (TAVR) procedures done transapically can lead to cardiac tamponade or ventricular pseudoaneurysm.
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We describe a case of ventricular pseudoaneurysm following trans-subclavian TAVR.
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Percutaneous closure was successful with an Amplatzer device.
Left ventricular pseudoaneurysms (LVP) represent an infrequent complication following myocardial infarction or cardiac procedures . Here, we present a case of an LVP occurring in a patient after transcatheter aortic valve implantation (TAVR) through a subclavian access.
An 81-year-old male with severe chronic obstructive pulmonary disease and severe aortic stenosis was referred for TAVR. He had previously undergone three-vessel coronary artery bypass graft surgery (left internal mammary artery to the left anterior descending and two saphenous vein grafts) in 2011 and endovascular abdominal aortic repair in 2012. Left ventricular ejection fraction was 60% and all bypass grafts were patent. Preoperatively, his surgical risk was deemed elevated by logistic Euroscore (35%) and STS score (33.8%). The patient underwent direct Corevalve (29 mm) implantation though a right subclavian access smoothly, without need for postdilation, using an Amplatz extra stiff wire with a 7-cm soft tip. There were no in-hospital complications and pre-discharge transthoracic echo was within normal limits. At 30-day routine visit, LVP was found by transthoracic echo and multi-slice computed tomography (MSCT, Figure A–D).
LVP closure was performed under light sedation, through the left femoral artery 8F access. Heparin was used for anticoagulation. Left ventriculography showed preserved systolic function and a large LVP on the anterolateral wall, near the apex ( Figure E ). The left ventricle was accessed retrograde across the Corevalve, and the LVP was localized and entered with a 5F right Judkins catheter and a 0.035″ hydrophilic angulated soft tip guide-wire. Then, we exchanged it to a high-support wire with a 1-cm soft pigtail tipped and advanced an 8F Sheath (Cook) to the ventricle introducing the soft distal tip into the pseudoaneurysm ( Figure F ). The wire was exchanged back and a 10-mm muscular ventricular septal defect occluder (Amplatzer™) was delivered and positioned under fluoro and transesophageal echo guidance without complications (Figure F–H). Repeat ventriculography showed almost no flow into the pseudoaneurysm (Figure G–H). Next day transthoracic echo showed similar findings, while some residual flow was found by MSCT (Figure I–J). The patient was discharged the following day. At 30 days, the patient remained asymptomatic and repeat echo and MSCT showed no flow into the pseudoaneurysm cavity (Figure K–L).
