Pseudoaneurysm after TAVR: how to close the hole?

Abstract

A 77-year-old man with symptomatic aortic stenosis was referred to our hospital for transcatheter aortic valve replacement (TAVR). Based on annulus and left ventricle outflow tract (LVOT) measurement, a 29-mm Edwards sapien 3 bioprosthesis (Edwards Lifesciences, Irvine, CA, USA) was implanted successfully using a transfemoral approach. Six months later the patient referred dizziness and physical examination revealed a diastolic murmur and high differencial pressure. The transtoracic echocardiogram disclosed a severe aortic regurgitation (AR) and a transesophageal echocardiogram showed a large cavity (*) connected to LVOT, with active flow inside. An urgent CT identified a large LVOT pseudoaneurysm (*) with a width neck 20×10 mm (Panel 1), extending below left main (LM, white arrow). The case was discussed by the Heart Team and a percutaneous approach was decided. From left humeral access and 71-cm AgilisTM NxT (Abbott, Chicago, IL,USA) steerable sheath it was possible to access the neck of the pseudoaneurysm (*). A 22-mm AmplatzerTM Vascular Plug II device (Abbott, Chicago, IL, USA) was implanted successfully (Panel 2, Video 1–3). The device sealed the cavity, leaving minimal residual flow. The AR was mild after this procedure. CT 24 h later showed a device sealing the neck of the .pseudoaneurysm at the level of LVOT (Panel 3). One month later, the patient was in NYHA class I; no events were reported and the CT confirmed the stability of the pseudoaneurysm.