P700 TEE guidance of percutaneous closure the inlet and exit of ascending aorta pseudoaneurysm in a patient had triple valve replacement

Abstract

Abstract Funding Acknowledgements none OnBehalf none Introduction Surgical treatment of ascending aortic pseudoaneurysms (AAPA) that develop following cardiac surgery carries significant morbidity and mortality. However, there are emerging reports of transcatheter closure of AAPA. To the best of our knowledge, this is the first reported case where the APA communicates with the left ventricle (LV) cavity with significant diastolic volume overload mimic severe aortic regurgitation. We added to the complications of APA, a fistulous communication with LV causing severe volume overload and heart failure. Case description: Thirty-two years old female underwent mechanical aortic and mitral valve replacement and bioprosthetic tricuspid valve replacement in April 2013. At October 2016, she started to have progressive shortness of breath. TEE revealed large ascending aorta pseudoaneurysm that communicates with LV cavity. Cardiac computed tomography (CT) with contrast revealed a sizeable noncoronary sinus of Valsalva pseudoaneurysm 47mm x 39mm. Surgical excision of the aneurysm decided, but the patient refused any surgical procedure. Percutaneous closure of the inlet and exit of the aneurysm discussed and accepted by the patient. The procedure of transcatheter aneurysm device closure performed successfully with TEE guidance (Figure). A: showed the aneurysm exit to the LV while D: showed its inlet from the aorta. The wire passed the aneurysm inlet at ascending aorta to its outlet in the LV (B). Six mm VSD device deployed closing the aneurysm exit to LV (C). Another 6mm VSD device deployed closing the aneurysm inlet (E). Transgastric long axis aorta view showed no more flow to LV. Midessophageal Short axis view showed no flow between ascending aorta and the aneurysm. Fluoroscopy injection inside the aneurysm (F), another two devices left inside the aneurysm (G). The patient was observed in the cardiac care unit (CCU) for two days, then discharged home in good condition. She was followed in the outpatient clinic after two weeks, and she is doing well with no more shortness of breath. Follow up echo after one year of the procedure showed a small remaining flow from the aneurysmal cavity to the left ventricle. (H and K) compares apical three-chamber view before and one year after closure. Discussion: Preprocedural CT and Intraprocedural TEE are mandatory in determining the size and location of AAPA. Also, the type and size of suitable devices for closure. Overall, the success rate for percutaneous closure is 80%, with a 12% device embolization rate and an 8% failure rate of the transcatheter technique to close the pseudoaneurysm, necessitating conversion to surgical closure. In most reported cases the AAPA had only communication with the aorta. In our case, the AAPA also communicates with the LV cavity that requires the closure of both communications. Conclusion: Percutaneous closure of the inlet and exit of AAPA with TEE guidance is feasible. Long term follow up is required in a large number of patients. Abstract P700 Figure: AAPA device closure