IJCA-17968; No of Pages 3 International Journal of Cardiology xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Percutaneous closure of a giant pseudoaneurysm of the ascending aorta after valve replacement Bili Zhang 1, Feng Chen 1, Suxuan Liu 1, Yongwen Qin, Xianxian Zhao ⁎ Department of Cardiology, Changhai Hospital, Second Military Medical University, Changhai Road 168, Shanghai 200433, China
a r t i c l e
i n f o
Article history: Received 13 March 2014 Received in revised form 2 April 2014 Accepted 4 April 2014 Available online xxxx Keywords: Ascending aortic aneurysm VSD closure device Percutaneous closure
A 45-year-old male who underwent aortic valve replacement 3 years ago was transferred to our institution on January 13, 2012. He presented with progressive dyspnea, palpitation, orthopnea, abdominal distension and lower limb edema, which developed 1 month after aortic valve replacement. Despite the use of excellent medical therapy, the patient had a deteriorating cardiac function. Cardiac auscultation revealed a grade 3/6 systolic murmur at the right upper sternal border. Chest radiograph showed bilateral pleural effusion, diffuse interstitial markings, and a hugely enlarged heart shadow with a spherical configuration on its right side. Computed tomography angiography (CTA) showed that an aortic pseudoaneurysm originated from an orifice (about 6 mm in diameter) in the ascending aorta. Transthoracic echocardiography (TTE) revealed the giant aortic pseudoaneurysm fistulating into the right atrium (Fig. 1). The fistula measured 10 mm at the diameter and the pseudoaneurysm measured 80 × 65 mm at the maximal echocardiographic diameters. Cardiac enlargement showed that the left atrial volume was 72 ml, the left ventricular volume was 118 ml and the right atrial volume was 96 ml with severe tricuspid regurgitation (12 ml). The ejection fraction was 40%. He was considered to be a high-risk candidate for repeat surgery and referred for percutaneous closure on January 15, 2012. An aortic angiogram was performed to confirm the presence of the giant pseudoaneurysm (online Video 1). A modified muscular occluder (Shanghai Shape Memory Alloy Ltd., China) similar to the Amplatzer occluder, was used in this procedure. It was made of a 0.005-in nitinol
⁎ Corresponding author. Tel./fax: +86 213 1161255. E-mail address: [email protected] (X. Zhao). 1 Co-first authors with equal contributions.
wire mesh with fabric inside and approved by the State Food and Drug Administration (SFDA) of China in 2003 (Fig. 2). The occluder was delivered via the right femoral artery using a 10-French delivery sheath. Final aortogram revealed that there was no residual flow into the pseudoaneurysm and the occluder was well-positioned (online Videos 2 and 3). The procedure was well tolerated by the patient and completely without immediate complications. Post-operative day 3, TTE demonstrated no residual flow across the pseudoaneurysm. CTA revealed that the occluder was well fixed into the neck of pseudoaneurysm (Fig. 3). At one-year follow-up, chest radiograph showed that the size of the pseudoaneurysm gradually decreased (Fig. 4). TTE showed no residual flow to the pseudoaneurysm, with an ejection fraction of 62%. The left atrial volume was 66 ml, the right atrial volume was 91 ml, and the right atrial volume had decreased from 118 ml to 97 ml. The volume of tricuspid regurgitation had decreased from 12 ml to 2 ml. Furthermore, the patient had no serious health problems and enjoyed a good quality of life during the follow-up. Ascending aortic pseudoaneurysm is an infrequent but exceptionally serious complication following cardiac surgeries [1]. Such aneurysm is predisposed to rupture, thrombosis, distal embolization, and fistula formation. Surgical repair is the conventional therapy but limited by poor outcomes and high mortality rates [2,3]. Nowadays percutaneous closure has been confirmed as an attractive alternative to surgery with encouraging immediate and short-term outcomes in some selected cases [4]. However the present case was a particularly difficult challenge for interventional cardiologists. First, the patient was at high risk for percutaneous closure due to his deteriorating cardiac function. Second, the aneurysm measured 80 × 65 mm at the maximal echocardiographic diameters with the formation of aorta–right atrium fistula. The pseudoaneurysm originated from the weakness in the tissue of the aortic wall. To avoid stretch-induced injury in aorta or pseudoaneurysm by moving the occluder back and forth, we decided to choose a 14-mm muscular occluder with a long connecting waist. We firstly released the right disk in the pseudoaneurysm and then released the left disk in the aortic wall. Final aortogram revealed that the occluder was well-positioned and there was no residual flow. To the best of our knowledge, this was the largest size recorded in patients with pseudoaneurysm undergoing percutaneous closure. We report the incidental finding of a giant aortic pseudoaneurysm associated with an aorta–right atrium fistula. Although the percutaneous closure was challenging, it was performed successfully. Percutaneous closure of aortic pseudoaneurysm is a safe and effective approach with excellent immediate and mid-term outcomes in the present case.
http://dx.doi.org/10.1016/j.ijcard.2014.04.067 0167-5273/© 2014 Elsevier Ireland. Ltd
Please cite this article as: Zhang B, et al, Percutaneous closure of a giant pseudoaneurysm of the ascending aorta after valve replacement, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.04.067
2
B. Zhang et al. / International Journal of Cardiology xxx (2014) xxx–xxx
Fig. 1. Pre-procedure imaging of the ascending aortic pseudoaneurysm. (A) Transthoracic echocardiography revealed the pseudoaneurysm of the ascending aorta fistulating to the right atrium. (B) Computed tomography angiography demonstrated the giant pseudoaneurysm originating from the ascending aorta. AAP, ascending aortic pseudoaneurysm; AO: aorta; RA: right atrium.
Such an intervention may become an attractive alternative to surgery for appropriately selected patients with ascending aortic pseudoaneurysm. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ijcard.2014.04.067. Acknowledgments We thank the referring cardiologists, surgeons and echocardiographers who supplied clinical and echocardiographic data. The authors of this manuscript have certified that they comply with the principles of ethical publishing in the International Journal of Cardiology [5]. References [1] Dumont E, Carrier M, Cartier R, et al. Repair of aortic false aneurysm using deep hypothermia and circulatory arrest. Ann Thorac Surg 2004;78:117–20 [discussion 20–1]. [2] Sullivan KL, Steiner RM, Smullens SN, Griska L, Meister SG. Pseudoaneurysm of the ascending aorta following cardiac surgery. Chest 1988;93:138–43. [3] Razzouk A, Gundry S, Wang N, et al. Pseudoaneurysms of the aorta after cardiac surgery or chest trauma. Am Surg 1993;59:818–23. [4] Kumar PV, Alli O, Bjarnason H, Hagler DJ, Sundt TM, Rihal CS. Percutaneous therapeutic approaches to closure of cardiac pseudoaneurysms. Catheter Cardiovasc Interv 2012;80:687–99. [5] Shewan LG, Rosano G, Henein M, Coats AJS. A statement on ethical standards in publishing scientific articles in the International Journal of Cardiology family of journals. Int J Cardiol 2014;170:253–4.
Fig. 2. Lateral view of the muscular ventricular septal defect occluder.
Please cite this article as: Zhang B, et al, Percutaneous closure of a giant pseudoaneurysm of the ascending aorta after valve replacement, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.04.067
B. Zhang et al. / International Journal of Cardiology xxx (2014) xxx–xxx
3
Fig. 3. Computed tomography angiography revealed the occluder was well fixed into the neck of pseudoaneurysm. (A) Sagittal view of the occluder and ascending aortic pseudoaneurysm. (B) Transverse view of the occluder and ascending aortic pseudoaneurysm. AAP, ascending aortic pseudoaneurysm; AO: aorta.
Fig. 4. Chest radiograph of the ascending aortic pseudoaneurysm. (A) Chest radiograph revealed the bilateral pleural effusion and the hugely enlarged heart shadow with the spherical configuration on its right side before the procedure. (B) Chest radiograph showed the bilateral pleural effusion disappeared on postoperative day 3. (C) Chest radiograph showed the size of the pseudoaneurysm gradually decreased at one-year follow-up.
Please cite this article as: Zhang B, et al, Percutaneous closure of a giant pseudoaneurysm of the ascending aorta after valve replacement, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.04.067
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Percutaneous closure of a giant pseudoaneurysm of the ascending aorta after valve replacement Bili Zhang 1, Feng Chen 1, Suxuan Liu 1, Yongwen Qin, Xianxian Zhao ⁎ Department of Cardiology, Changhai Hospital, Second Military Medical University, Changhai Road 168, Shanghai 200433, China
a r t i c l e
i n f o
Article history: Received 13 March 2014 Received in revised form 2 April 2014 Accepted 4 April 2014 Available online xxxx Keywords: Ascending aortic aneurysm VSD closure device Percutaneous closure
A 45-year-old male who underwent aortic valve replacement 3 years ago was transferred to our institution on January 13, 2012. He presented with progressive dyspnea, palpitation, orthopnea, abdominal distension and lower limb edema, which developed 1 month after aortic valve replacement. Despite the use of excellent medical therapy, the patient had a deteriorating cardiac function. Cardiac auscultation revealed a grade 3/6 systolic murmur at the right upper sternal border. Chest radiograph showed bilateral pleural effusion, diffuse interstitial markings, and a hugely enlarged heart shadow with a spherical configuration on its right side. Computed tomography angiography (CTA) showed that an aortic pseudoaneurysm originated from an orifice (about 6 mm in diameter) in the ascending aorta. Transthoracic echocardiography (TTE) revealed the giant aortic pseudoaneurysm fistulating into the right atrium (Fig. 1). The fistula measured 10 mm at the diameter and the pseudoaneurysm measured 80 × 65 mm at the maximal echocardiographic diameters. Cardiac enlargement showed that the left atrial volume was 72 ml, the left ventricular volume was 118 ml and the right atrial volume was 96 ml with severe tricuspid regurgitation (12 ml). The ejection fraction was 40%. He was considered to be a high-risk candidate for repeat surgery and referred for percutaneous closure on January 15, 2012. An aortic angiogram was performed to confirm the presence of the giant pseudoaneurysm (online Video 1). A modified muscular occluder (Shanghai Shape Memory Alloy Ltd., China) similar to the Amplatzer occluder, was used in this procedure. It was made of a 0.005-in nitinol
⁎ Corresponding author. Tel./fax: +86 213 1161255. E-mail address: [email protected] (X. Zhao). 1 Co-first authors with equal contributions.
wire mesh with fabric inside and approved by the State Food and Drug Administration (SFDA) of China in 2003 (Fig. 2). The occluder was delivered via the right femoral artery using a 10-French delivery sheath. Final aortogram revealed that there was no residual flow into the pseudoaneurysm and the occluder was well-positioned (online Videos 2 and 3). The procedure was well tolerated by the patient and completely without immediate complications. Post-operative day 3, TTE demonstrated no residual flow across the pseudoaneurysm. CTA revealed that the occluder was well fixed into the neck of pseudoaneurysm (Fig. 3). At one-year follow-up, chest radiograph showed that the size of the pseudoaneurysm gradually decreased (Fig. 4). TTE showed no residual flow to the pseudoaneurysm, with an ejection fraction of 62%. The left atrial volume was 66 ml, the right atrial volume was 91 ml, and the right atrial volume had decreased from 118 ml to 97 ml. The volume of tricuspid regurgitation had decreased from 12 ml to 2 ml. Furthermore, the patient had no serious health problems and enjoyed a good quality of life during the follow-up. Ascending aortic pseudoaneurysm is an infrequent but exceptionally serious complication following cardiac surgeries [1]. Such aneurysm is predisposed to rupture, thrombosis, distal embolization, and fistula formation. Surgical repair is the conventional therapy but limited by poor outcomes and high mortality rates [2,3]. Nowadays percutaneous closure has been confirmed as an attractive alternative to surgery with encouraging immediate and short-term outcomes in some selected cases [4]. However the present case was a particularly difficult challenge for interventional cardiologists. First, the patient was at high risk for percutaneous closure due to his deteriorating cardiac function. Second, the aneurysm measured 80 × 65 mm at the maximal echocardiographic diameters with the formation of aorta–right atrium fistula. The pseudoaneurysm originated from the weakness in the tissue of the aortic wall. To avoid stretch-induced injury in aorta or pseudoaneurysm by moving the occluder back and forth, we decided to choose a 14-mm muscular occluder with a long connecting waist. We firstly released the right disk in the pseudoaneurysm and then released the left disk in the aortic wall. Final aortogram revealed that the occluder was well-positioned and there was no residual flow. To the best of our knowledge, this was the largest size recorded in patients with pseudoaneurysm undergoing percutaneous closure. We report the incidental finding of a giant aortic pseudoaneurysm associated with an aorta–right atrium fistula. Although the percutaneous closure was challenging, it was performed successfully. Percutaneous closure of aortic pseudoaneurysm is a safe and effective approach with excellent immediate and mid-term outcomes in the present case.
http://dx.doi.org/10.1016/j.ijcard.2014.04.067 0167-5273/© 2014 Elsevier Ireland. Ltd
Please cite this article as: Zhang B, et al, Percutaneous closure of a giant pseudoaneurysm of the ascending aorta after valve replacement, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.04.067
2
B. Zhang et al. / International Journal of Cardiology xxx (2014) xxx–xxx
Fig. 1. Pre-procedure imaging of the ascending aortic pseudoaneurysm. (A) Transthoracic echocardiography revealed the pseudoaneurysm of the ascending aorta fistulating to the right atrium. (B) Computed tomography angiography demonstrated the giant pseudoaneurysm originating from the ascending aorta. AAP, ascending aortic pseudoaneurysm; AO: aorta; RA: right atrium.
Such an intervention may become an attractive alternative to surgery for appropriately selected patients with ascending aortic pseudoaneurysm. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ijcard.2014.04.067. Acknowledgments We thank the referring cardiologists, surgeons and echocardiographers who supplied clinical and echocardiographic data. The authors of this manuscript have certified that they comply with the principles of ethical publishing in the International Journal of Cardiology [5]. References [1] Dumont E, Carrier M, Cartier R, et al. Repair of aortic false aneurysm using deep hypothermia and circulatory arrest. Ann Thorac Surg 2004;78:117–20 [discussion 20–1]. [2] Sullivan KL, Steiner RM, Smullens SN, Griska L, Meister SG. Pseudoaneurysm of the ascending aorta following cardiac surgery. Chest 1988;93:138–43. [3] Razzouk A, Gundry S, Wang N, et al. Pseudoaneurysms of the aorta after cardiac surgery or chest trauma. Am Surg 1993;59:818–23. [4] Kumar PV, Alli O, Bjarnason H, Hagler DJ, Sundt TM, Rihal CS. Percutaneous therapeutic approaches to closure of cardiac pseudoaneurysms. Catheter Cardiovasc Interv 2012;80:687–99. [5] Shewan LG, Rosano G, Henein M, Coats AJS. A statement on ethical standards in publishing scientific articles in the International Journal of Cardiology family of journals. Int J Cardiol 2014;170:253–4.
Fig. 2. Lateral view of the muscular ventricular septal defect occluder.
Please cite this article as: Zhang B, et al, Percutaneous closure of a giant pseudoaneurysm of the ascending aorta after valve replacement, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.04.067
B. Zhang et al. / International Journal of Cardiology xxx (2014) xxx–xxx
3
Fig. 3. Computed tomography angiography revealed the occluder was well fixed into the neck of pseudoaneurysm. (A) Sagittal view of the occluder and ascending aortic pseudoaneurysm. (B) Transverse view of the occluder and ascending aortic pseudoaneurysm. AAP, ascending aortic pseudoaneurysm; AO: aorta.
Fig. 4. Chest radiograph of the ascending aortic pseudoaneurysm. (A) Chest radiograph revealed the bilateral pleural effusion and the hugely enlarged heart shadow with the spherical configuration on its right side before the procedure. (B) Chest radiograph showed the bilateral pleural effusion disappeared on postoperative day 3. (C) Chest radiograph showed the size of the pseudoaneurysm gradually decreased at one-year follow-up.
Please cite this article as: Zhang B, et al, Percutaneous closure of a giant pseudoaneurysm of the ascending aorta after valve replacement, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.04.067
