Left Ventricular Perforation Research Articles

Delayed presentation of acute coronary syndrome with mechanical complication during COVID-19 pandemic: a case report

BackgroundThe World Health Organization declared coronavirus disease 2019 (COVID-19) a global pandemic on 11 March 2020. We report a patient with acute myocardial infarction (AMI) who presented late due to fears of contracting COVID-19.Case summaryA 65-year-old man with a history of hypertension presented late to the emergency department (ED) with AMI. He gave a 2-month history of exertional angina but avoided seeking medical consult due to fears of contracting COVID-19. On the day of admission, he had 4 h of severe chest pain before presenting to the ED. He was hypotensive and tachycardic on arrival. Electrocardiogram showed inferolateral ST-elevation myocardial infarction. Chest radiograph revealed widened superior mediastinum and bedside echocardiogram revealed inferoseptal and inferolateral hypokinesia with features of cardiac tamponade. An urgent computed tomography aortogram showed possible left ventricular (LV) wall perforation with resulting haemopericardium and cardiac tamponade. Subsequent coronary angiogram showed 100% occlusion of mid left circumflex artery and a contained LV wall rupture was confirmed with LV ventriculogram. He was transferred to a tertiary centre and underwent successful emergency surgical repair.DiscussionOur index case demonstrates the impact of the COVID-19 pandemic on health seeking behaviour due to fears of contracting COVID-19 and the ensuing impact of delayed medical intervention. Cardiologists worldwide are seeing an alarming rate of rare complications of AMI in patients who present late. Physicians need to be aware of this phenomenon and have an active role to play in public education.

Peri-procedural tamponade following TAVI: Incidence, predictors and impact on outcome

Transcatheter aortic valve implantation (TAVI) has revolutionized the treatment of severe symptomatic aortic stenosis. However, cardiac tamponade remains a threatening complication with few reported data. To investigate the incidence, causes, predictive factors and outcomes of peri-procedural tamponade among TAVI patients. This study included the patients who consecutively underwent TAVI in two high-volume centres between 2006 and 2017. Baseline characteristics of the patients, procedural details and hospital outcomes were prospectively recorded. A total of 1957 patients were included (Age: 81.8 ± 2.1 years; male gender, 46%; logistic Euroscore: 16.9 ± 2.9%). A peri-procedural tamponade occurred in n = 51 patients (2.6%). The incidence decreased significantly over time: 5.8% for the 2006–2008 period, 3.6% for the 2009–2011 period, 3.5% for the 2012–2014 period and 1.7% for the 2015–2017 period ( P = 0.03). The causes were: left ventricular perforation by the stiff wire in n = 12 patients (24%), right ventricular perforation by pacing leading in n = 9 patients (17%), annular rupture in n = 12 patients (24%). There was no reported cause in 35% of the cases. The patients were treated by percutaneous pericardiocentesis in n = 20 cases (39%), cardiac surgery in n = 28 cases (55%) and hemodynamic support only in n = 3 cases (6%). Patient age (OR = 1.06 (95% CI: 1.01–1.11) per year), baseline left ventricle ejection fraction (OR = 1.03 (1.00–1.07) per %), previous chest radiation (OR = 3.60 (1.5–8.5)) and non-transfemoral access (OR = 2.70 (1.25–8.84)) were independent predictors of peri-procedural tamponade. The occurrence of tamponade severely impaired outcome: the actuarial 30-day survival was 66.4 ± 6.6% in tamponade patients vs. 96.8% ± 0.4% in the others ( P < 0.001, log rank test). Cardiac tamponade during TAVI is a rare complication whose incidence decreased over past years but remains associated with a poor immediate outcome.

A Case of Left Ventricular Perforation Caused by Guidewire Insertion during Trans-Catheter Aortic Valve Implantation

A Case of Left Ventricular Perforation Caused by Guidewire Insertion during Trans-Catheter Aortic Valve Implantation

Incidence and outcomes of emergent cardiac surgery during transfemoral transcatheter aortic valve implantation (TAVI): insights from the European Registry on Emergent Cardiac Surgery during TAVI (EuRECS-TAVI).

Life-threatening complications occur during transcatheter aortic valve implantation (TAVI) which can require emergent cardiac surgery (ECS). Risks and outcomes of patients needing ECS during or immediately after TAVI are still unclear. Incidence, risk factors, management, and outcomes of patients requiring ECS during transfemoral (TF)-TAVI were analysed from a contemporary real-world multicentre registry. Between 2013 and 2016, 27760 patients underwent TF-TAVI in 79 centres. Of these, 212 (0.76%) patients required ECS (age 82.4 ± 6.3 years, 67.5% females, logistic EuroSCORE: 17.1%, STS-score 5.8%). The risk of ECS declined from 2013 (1.07%) to 2014 (0.70%) but remained stable since. Annual TF-TAVI numbers have more than doubled from 2013 to 2016. Leading causes for ECS were left ventricular perforation by the guidewire (28.3%) and annular rupture (21.2%). Immediate procedural mortality (<72 h) of TF-TAVI patients requiring ECS was 34.6%. Overall in-hospital mortality was 46.0%, and highest in case of annular rupture (62%). Independent predictors of in-hospital mortality following ECS were age > 85 years [odds ratio (OR) 1.87, 95% confidence interval (95% CI) (1.02-3.45), P = 0.044], annular rupture [OR 1.96, 95% CI (0.94-4.10), P = 0.060], and immediate ECS [OR 3.12, 95% CI (1.07-9.11), P = 0.037]. One year of survival of the 114 patients surviving the in-hospital period was only 40.4%. Between 2014 and 2016, the need for ECS remained stable around 0.7%. Left ventricular guidewire perforation and annular rupture were the most frequent causes, accounting for almost half of ECS cases. Half of the patients could be salvaged by ECS-nevertheless, 1 year of all-cause mortality was high even in those ECS patients surviving the in-hospital period.

Inadvertent left ventricular pacing and perforation by a temporary pacemaker

Myocardial perforation by pacemaker electrode is a very serious complication. Usually, the pacemaker electrode perforates the right ventricle, but rarely the left ventricular myocardium. We describe an 82-year-old female patient who presented with left ventricular pacing after temporary pacemaker implantation and was diagnosed with myocardial perforation. Emergency thoracotomy showed that the exact position of the cardiac perforation was close to the left ventricular apex. Perforation of the left ventricular free wall by an electrode sometimes progresses slowly. We should be alert to the possibility of left ventricular perforation, in which case, immediate surgery is the best option.

Left ventricular perforation in a patient with a left ventricular aneurysm during NOGA® catheter mapping

Endocardial mapping of the left ventricle (LV) using the NOGA® XP Cardiac Navigation System can identify chronically ischemic and viable myocardium in patients with coronary artery disease by generating electromechanical maps. These maps are very useful when targeting myocardial tissue for injection of stem cells. We present the case of a woman who developed a perforation at the site of an LV aneurysm during NOGA mapping prior to the transendocardial injection of stem cells, as part of a multicenter clinical trial. The presence of an LV aneurysm is currently not a contraindication (or caution) to the use the NOGA mapping catheter. As the field of stem cell therapy evolves and the use of this technique increases, operators must be aware that the presence of an LV aneurysm may increase the risk of perforation during a NOGA mapping procedure.

Left Ventricular Perforation in A Patient with Lung Cancer Treated with Bevacizumab

In addition to traditional chemotherapeutic regimens molecular targeted agents emerged as new therapeutic options for the treatment of non-small-cell lung cancer (NSCLC). These targeted therapies do not have the same systemic adverse effects usually observed with traditional cytotoxic drugs, but feature a specific spectrum of characteristic adverse effects. The humanized monoclonal antibody against the VEGF-A ligand Bevacizumab inhibits angiogenesis. The characteristic toxicities of Bevacizumab include hemorrhage, wound healing complications, gastrointestinal perforation, arterial thromboembolism, and infusion-related hypersensitivity reactions. We present a unique case of a left ventricular wall perforation after myocardial infarction associated with the administration of Bevacizumab in NSCLC. Cardiac MRI follow-up showed regression of the ventricular perforation.

Ischemic Left Ventricular Perforation Covered by a Thrombus in a Patient Presenting with Cerebral Ischemia: Importance of Time-Sensitive Performance and Adequate Interpretation of Bedside Transthoracic Echography.

If myocardial infarction remains silent, only clinical signs of complications may unveil its presence. Life-threatening complications include myocardial rupture, thrombus formation, or arterial embolization. In the presented case, a 76-year-old patient was admitted with left-sided hemiparesis. In duplex sonography, a critical stenosis of the right internal carotid artery was identified and initially but retrospectively incorrectly judged as the potential cause for ischemia. During operative thromboendarterectomy, arterial embolism of the right leg occurred coincidentally, more likely pointing towards a cardioembolic origin. Percutaneous interventions remained unsuccessful and local fibrinolysis was applied. Delayed bedside echocardiography by an experienced cardiologist demonstrated a discontinuity of the normal myocardial texture of the left ventricular apex together with an echodense, partly floating structure merely attached by a thin bridge not completely sealing the myocardial defect, accompanied by pericardial effusion. The patient was immediately transferred to emergency cardiac surgery with extirpation of the thrombus, aortocoronary bypass graft placement, and aneurysmectomy. This didactic case reveals decisive structural shortcomings in patient's admission and triage processes and underlines, if performed timely and correctly, the value of transthoracic echocardiography as a noninvasive and cost-effective tool allowing immediate decision-making, which, in this case, led to the correct but almost fatally delayed diagnosis.

Left ventricular pseudoaneurysm following balloon mitral valvuloplasty

Balloon mitral valvotomy is a commonly performed procedure for mitral stenosis. This procedure can lead to complications such as left ventricular perforation with tamponade, mitral regurgitation and stroke. Here we report a case of left ventricular pseudoaneurysm following balloon mitral valvotomy. It was a consequence of adherent pericardium secondary to open mitral valvotomy performed earlier. It was surgically corrected by pseudoaneurysm repair and mitral valve replacement. We believe that this is the first such reported case.

Emergency cardiac surgery during transfemoral and transapical transcatheter aortic valve implantation: Incidence, reasons, management, and outcome of 411 patients from a single center

Transcatheter aortic valve implantation (TAVI) is increasingly performed in high-risk patients with severe aortic valve stenosis. Incidence and impact of emergency cardiac surgery (ECS) during TAVI is unclear. Two-hundred twenty one transapical (TA) and 190 transfemoral (TF) TAVIs were performed at our hospital between 01/2009 and 12/2012. Twenty patients (4.9%) required ECS, more frequently in the TF- (n = 11; 5.8%) than in the TA-group (n = 9; 4.1%; P = 0.017). ECS-cases were evenly distributed throughout the 4 years. Baseline characteristics of the ECS-patients were not different from the non-ECS-patients. Reasons were acute cardiac failure, coronary obstruction, annular rupture, valve migration, right- and left-ventricular perforation, severe paravalvular leakage, aortic dissection, and mitral valve damage. Surgical intervention consisted of peripheral CPB, switch to TA, thoracotomy and suture of perforated cardiac chambers and conventional aortic valve replacement with concomitant repair of associated cardiovascular injury. Thirty-day mortality was 35.0%, and 55.0% could be salvaged to hospital discharge. Kaplan-Meier 1-year survival curves were significantly impaired for patients requiring ECS (TF: P < 0.0001, HR 8.716; TA: P = 0.013, HR 2.813). Life-threatening complications requiring bail-out ECS occur in a substantial proportion during TAVI. ECS dramatically affects early and late outcome after TAVI. Under optimal conditions more than half of the ECS-patients can be salvaged. With the current technology of THV-systems ECS should be an integral part of the logistic conditions surrounding TAVI and is far from being futile in this patient population.

An unusual complication of infective endocarditis: left ventricular outflow tract perforation

A 24-year-old female was admitted to our hospital complaining of fever, chest pain, cough and dyspnoea. Physical examination revealed tachycardia with heart rate 115 bpm, dull and decreased respiratory sounds in the lower left lung field, systolodiastolic murmur at the aortic and mesocardiac area. Chest X-ray showed an increased cardiothoracic ratio and left-sided pleural effusion. The erythrocyte sedimentation rate was found to be 64 mm/h. Echocardiography revealed moderate aortic insufficiency. Pathological flow was detected at left ventricular outflow tract (LVOT) by Doppler imaging. LV free wall was seen to be compressed partially by the haematoma surrounding the heart. Chest computed tomography (CT) showed the perforation at LVOT, partial compression of LV lateral wall, main pulmonary artery, superior vena cava, and nearly complete obstruction of left pulmonary veins (Figs. 1–3). The patient underwent emergent cardiac surgery. A pseudoaneurysm sac was detected starting from the lateral side of the aorta extending through transverse sinus and including the left anterior descending coronary artery region. Aortotomy was performed. The aortic valve was detected to be bicuspid. A perforation with a diameter of 10 × 15 mm was seen just below the aortic valve (Fig. 4). The perforation was repaired with a dacron graft, and aortic valve replacement was performed. The pathological examination revealed inflammation and vegetation at the sample taken from the perforation region, which demonstrated that the aetiology of perforation was mural infective endocarditis. Mural endocarditis is an inflammation and disruption of the nonvalvular endocardial surface of the cardiac chambers. Mural endocarditis may develop on LVOT secondary to chronic aortic regurgitation due to chronic endocardial trauma. Traumatised endocardium provides a nidus for the development of bacterial vegetation. It is well known that inflammation and vegetation may cause destructive lesions and perforation usually affecting valves, and result in acute valvular regurgitation, or may result in fistula formation. But myocardial perforation and pseudoaneurysm formation has rarely been reported. Excision of the pseudoaneurysm with LV reconstruction should be the treatment of choice in patients presenting with myocardial perforation and pseudoaneurysm formation.

Near-fatal cardiac arrest due to cardiac tamponade during percutaneous mitral valvuloplasty

The incidence of hemopericardium following percutaneous mitral valvuloplasty is reported at 1–3%, being related to either trans-septal puncture, or left ventricular perforation with guide wires or balloons. We report a case of percutaneous mitral valvuloplasty for a middle-aged man with moderately severe rheumatic mitral stenosis. The procedure was performed through a right femoral vein approach, employing the multitrack technique, utilizing 2 balloons (20 and 18 mm). Inadvertently, the procedure was complicated by cardiac tamponade. Despite immediate diagnosis and prompt pericardiocentesis, hemodynamic stability was not maintained. Echocardiography revealed a mass in the posterior pericardial sac. The patient was arrested in asystole, and rigorously resuscitated during transfer to the operating room. Exploration revealed a tear in the left ventricular apex that was adequately sutured. In a few days, the patient gradually regained adequate consciousness, and was ultimately discharged. Post-procedural echocardiography revealed a mitral valve area of 1.9 cm2, with no mitral regurgitation.

Uncommon Cause of Left Ventricular Pseudoaneurysm: Case Report and Review of Literature

We report a case of an 18-year-old man without tuberculosis history who presented with chest distress, dyspnea, and fever. Chest computed tomography scan and echocardiography showed left ventricular posterior wall pseudoaneurysm and perforation. Unfortunately, the patient died shortly after surgery. On the basis of surgical pathology, we made a final diagnosis of tuberculous pericarditis complicated with left ventricular pseudoaneurysm. This has not been reported before in the published literature.

Severe intraprocedural complications after transcatheter aortic valve implantation: calling for a heart team approach†

Transcatheter aortic valve implantation (TAVI) has emerged rapidly. Despite unanimous recommendations and potentially fatal intraoperative complications, the heart-team approach is not comprehensively adopted by all centres. We sought to characterize severe intraprocedural complications during TAVI requiring immediate surgical or interventional bailout manoeuvres and evaluate outcomes. TAVI was performed in 458 consecutive patients using a balloon-expandable or self-expanding valve through transfemoral and transapical approaches. Severe intraprocedural complications requiring intraoperative bailout manoeuvres were analysed according to the Valve Academic Research Consortium (VARC) criteria. Thirty-five of 458 patients (7.6%) experienced 40 major intraprocedural complications during TAVI, 13 (2.8%) requiring emergent conversion to surgery. Complications included valve embolization/migration (17%), severe aortic regurgitation (12%) and root rupture (5%), requiring immediate implantation of a second valve or conversion to surgical valve replacement. Sternotomy and surgical haemostasis were performed in 5 patients (13%) with left ventricular wire perforation and subsequent cardiac tamponade. Coronary obstruction (15%) required emergent percutaneous coronary intervention in 6 patients. At 30 days, all-cause mortality was 31.4% in patients with intraprocedural complications and 38.5% in patients requiring surgical conversion. However, mid-term survival after 30 days and exercise tolerance in surviving patients were comparable with patients undergoing uncomplicated TAVI. An interdisciplinary approach to TAVI facilitated bailout procedures accomplishing acceptable outcomes, despite severe intraprocedural complications. These bailout manoeuvres in potentially fatal complications were only accomplished through an interdisciplinary heart-team effort, creating a surgical and interventional safety net, which should be established in all centres performing TAVI procedures.

Left ventricular perforation by a guidewire crossing a stenotic calcific aortic valve

With the availability of better technology in catheterization techniques, perforation of myocardium during cardiac catheterization is a rare event. We report, a 65-year old male who developed this potentially life threatening complication, after several attempts were made to cross a heavily stenotic aortic valve. With this case presentation, we aim to call attention to this complication which we think it will occur more frequently in the era of percutenous aortic valve replacement.

Late Left Ventricular Perforation by Active Fixation Pacemaker Lead Implanted in the Right Ventricular Septum

We report a rare case of late left ventricular perforation caused by a migrated pacemaker lead, which had been implanted in the right ventricular septum three months prior. Preoperative computed tomography findings revealed that the tip of the migrated pacemaker lead had perforated the ventricular wall near the intraventricular groove into the anterior chest wall.

Left ventricular perforation and dissecting subepicardial hematoma after catheter ablation for Wolff-Parkinson-White syndrome

Radiofrequency catheter ablation of accessory bypass tracts has become a widely accepted therapy for Wolff-Parkinson-White (WPW) syndrome. The procedure typically has a high success rate with a low incidence of complications. Left ventricular perforation is a rare but serious complication of catheter ablation. Here we describe a patient who developed left ventricular perforation and a dissecting subepicardial hematoma with cardiac tamponade following catheter ablation for WPW syndrome. Immediate hematoma evacuation and direct repair of the fragile myocardium were performed under cardiopulmonary bypass, and the patient survived with no further complications.

Left Ventricular Perforation During Cooled-Tip Radiofrequency Ablation for Ischemic Ventricular Tachycardia

A 69-year-old man with a history of ischemic cardiomyopathy who had multiple implantable cardioverter-defibrillator shocks for sustained monomorphic ventricular tachycardia (Vt) despite antiarrhythmic therapy underwent Vt ablation. Because of the patient's severe peripheral vascular disease, left ventricular (LV) access was obtained via transseptal access using a Brockenbrough needle (BRK, St Jude Medical, Minnetonka, MN) over a medium curve, 8.5F Agilis sheath (St Jude Medical) under fluoroscopy and intracardiac ultrasound (ICE) guidance (AcuNav, Siemens, Mountainview, CA). Systemic heparin was given with the activated clotting time ranging from 250 to 340 seconds. A 7.5F bidirectional, deflectable, 3.5-mm-tip, external-irrigated ablation catheter (EZ STEER ThermoCool, Biosense Webster, Diamond Bar, CA) was advanced into the LV, and an electroanatomic map was created using the CARTO 3 mapping system (Biosense Webster). A large endocardial inferobasal scar was seen on the voltage map. Programmed electric stimulation and burst pacing were performed from several right ventricular and LV sites with 3 drive train cycle lengths and up to triple extrastimuli with a minimal coupling interval of 200 ms. During programmed electric stimulation, Vt was induced with a right bundle-branch block morphology, right superior axis, and a tachycardia cycle length of 537 ms, matching the leadless electrogram morphology of the clinical Vt. Pace mapping at the lateral edge of the inferobasal scar showed a 12/12 pm correlation with the clinical Vt …

Catheter tip force required for mechanical perforation of porcine cardiac chambers

Catheter manipulation during ablation procedures can produce injury and tamponade. We evaluated the mechanical forces required to perforate a porcine heart with an ablation catheter. A 7 Fr, 3.5 mm irrigated radiofrequency (RF) ablation catheter with a force sensor (FS) within its tip was used to create right atrial (RA) free wall lesions in pigs. The intact heart was removed and the FS-equipped catheter was used to mechanically perforate (without RF delivery) the free walls of both atria and ventricles: directly and through an introducer sheath to prevent catheter shaft buckling. Perforation was also performed through epicardially visible RA lesions and adjacent unablated tissue. Twenty-four RA free wall lesions were created in four pigs. One hundred and forty-four mechanical perforations were performed: 44 RA, 30 left atrial (LA), 37 right ventricular (RV), and 33 left ventricular (LV). The RA and RV perforation force (PF) was lower than through the LA and LV (P<0.0001). The LV perforation time was shorter when the catheter was gripped through an introducer sheath (0.8±0.5 vs. 3.2±3 s, P<0.0001). Perforation force through transmural RA lesions was lower than through unablated RA tissue (172.4±79.1 vs. 300.6±116.8 g, P<0.0002). The force threshold for mechanical perforation in the porcine heart is lower for right- compared with left-sided chambers, and also lower through recently created RA RF lesions compared with unablated RA tissue. Left ventricular perforation is achieved more rapidly with the ablation catheter in a sheath despite the same PF because the sheath prevents catheter buckling.

Fragmentation, Embolization, and Left Ventricular Perforation of a Recovery Filter

The Recovery retrievable inferior vena cava filter (C. R. Bard, Tempe, Arizona) was approved in the United States for temporary and permanent prophylaxis against pulmonary embolism. A few reports in the literature document fracture and migration of the Recovery filter or filter fragments into the heart. The authors report a case of delayed intracardiac migration of a fractured wire from this filter and describe the clinical course of a patient in whom this complication was managed.