Author + information
- Received January 11, 2012
- Revision received February 9, 2012
- Accepted February 18, 2012
- Published online August 1, 2012.
- ↵⁎Reprint requests and correspondence
: Dr. Ewa Peszek-Przybyla, Structural Heart Diseases Department, Upper Silesian Medical Center, ul. Ziolowa 45-47, 40-635 Katowice, Poland
A 67-year-old woman, with a history of inferior wall myocardial infarction, presented at a general hospital with a 4-week history of sudden onset heart failure in New York Heart Association functional class III. Echocardiography revealed inferior wall pseudoaneurysm formation, probably because of recent myocardial infarction (Fig. 1A). Because the patient refused the proposal of immediate surgical treatment, we planned a percutaneous procedure. Coronary angiography revealed occlusion of the peripheral segment of the right coronary artery, multilevel critical stenoses in the left anterior descending coronary artery (LAD), and rupture of the left ventricular inferior wall with opacification of a pseudoaneurysm cavity (Fig. 1B). Cardiac imaging was supplemented by multidetector computed tomography, which visualized the pseudoaneurysm cavity (Fig. 1C) and noticeably thinned necrotic tissue within the inferior wall and allowed us to precisely determine the relation between rupture site and papillary muscle (Fig. 1D). Therefore, we decided that a staged procedure should be performed: a percutaneous closure of the pseudoaneurysm, and afterward elective LAD angioplasty. A pigtail catheter was introduced transfemorally into the left ventricle, and another one—via transbrachial access with a 7-F sheath—served as a gateway for the closing device delivery system. The procedure was performed under fluoroscopic and transthoracic echocardiographic guidance. During the implantation, the pigtail catheter was used to temporarily move the papillary muscle body away from the lesion (Fig. 2A). This technique facilitated accurate placement and full expansion of an 8-mm Amplatzer Septal Occluder. As a result, complete sealing of the pseudoaneurysm orifice was achieved. Moreover, originally moderate ischemic mitral regurgitation diminished to trivial instantaneously (probably due to ventricle geometry improvement promoted by inferior wall stabilization). No early complications occurred; and after 2 days, the patient, in New York Heart Association functional class I, was discharged from the hospital. Three weeks later complete pseudoaneurysm closure was confirmed by echocardiography (Fig. 2B), multislice computed tomography (Fig. 2C), and ventriculography (Fig. 2D), and elective LAD angioplasty with implantation of 2 drug-eluting stents was performed. At 6-month follow-up, the result of the aforementioned staged procedure was satisfactory, and our patient was asymptomatic.
All authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received January 11, 2012.
- Revision received February 9, 2012.
- Accepted February 18, 2012.
- American College of Cardiology Foundation