https://orcid.org/0000-0002-4297-3199
A 76-year-old female patient who had undergone quadruple coronary bypass surgery and aortic valve replacement 10 years earlier was referred to our clinic for severe symptomatic mitral valve stenosis secondary to extensive mitral annular calcification (MAC). Due to the high surgical risk, the excessive MAC and no possibility of an interventional approach for anatomical reasons the Heart Team opted for a hybrid approach (sternotomy with surgical transatrial mitral Valve-In-MAC procedure using a balloon-expandable Edwards SAPIEN-3 29 mm prosthesis). The intervention was successful and the patient was discharged 13 days after surgery. Despite an uneventful recovery, a transthoracic echocardiography 30 days later (Panel A) showed a left ventricular (LV) discontinuity with a paraventricular cavity suggestive of a pseudoaneurysm (astir). Computed tomography (Panel B) and angiography (Panel C) confirmed the diagnosis of a ‘bilobular’ covered perforation connecting with the LV through a narrow neck (white arrow). The most likely explanation was inadvertent LV perforation during surgical valve implantation with the tip of the valve delivery catheter. Via retrograde aortic access, using live echocardio-angiographic fusion imaging guidance, the perforation was successfully engaged with a Judkins right catheter and the neck occluded with an Amplatzer Vascular Plug II. Immediate cessation of blood flow into the pseudoaneurysm could be documented by angiography (Panel F). Control computed tomography (Panel E) and discharge echocardiography (Panel D) confirmed the position of the device (yellow arrow) and the lack of contrast enhancement in the perforation. After full recovery, the patient could be discharged home.
