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Percutaneous Closure of a Left Atrial Appendage Pseudoaneurysm
CASE REPORTS
Percutaneous Closure of a Left Atrial Appendage Pseudoaneurysm Dale Yoo, MD, Gregory Robertson, MD, Peter Block, MD, Vasilis Babaliaros, MD, Omar Lattouf, MD, PhD, Maria-Alexandra Pernetz, RDCS, Randolph Martin, MD, Joel Felner, MD, and Stamatios Lerakis, MD, Atlanta, Georgia
Atrial dissections and pseudoaneurysms are rare complications of cardiac surgery. The authors describe the case of a patient after mitral valve replacement who presented with a left atrial appendage pseudoaneurysm. This case represents the first known closure of an atrial pseudoaneurysm with a percutaneous septal occluder device. (J Am Soc Echocardiogr 2011;24:109.e1-109.e3.) Keywords: Pseudoaneurysm, Atrium, Appendage, Percutaneous closure
Atrial dissections and pseudoaneurysms are rare complications of cardiac surgery.1,2 There are few reported cases of such complications in the literature, with most of them revealing themselves within days to weeks of the original surgery and requiring open cardiac repair.3-7 We describe the case of a patient after mitral valve replacement who presented nearly 2 months after surgery with a left atrial appendage (LAA) pseudoaneurysm. Moreover, this case represents the first known closure of a pseudoaneurysm with a percutaneous septal occluder device, usually reserved for patent foramen ovale and atrial septal defects.
CASE PRESENTATION A 53-year-old male with end-stage renal disease presented to the hospital for left knee pain and was diagnosed with villonodular synovitis. Following knee surgery, he became tachycardic and dyspneic, and cardiology was consulted. Transthoracic echocardiography and cardiac magnetic resonance imaging were performed and revealed a vegetation of the anterior leaflet of the mitral valve. Multiple blood cultures were drawn, which remained negative throughout the hospitalization. Because of the severity of the endocarditis, the patient underwent mitral valve replacement with a Medtronic 29-mm Mosaic bioprosthetic valve (Medtronic, Inc, Minneapolis, MN). The native mitral valve was sent to microbiology and all cultures, including fungal, acid-fast bacillus, and bacterial, were negative. Pathology revealed severe necrotizing endocarditis, with purulent inflammation. After a complicated postsurgical course, including ventilator-associated pneumonia and transient sinus node dysfunction with paroxysmal atrial fibrillation, the patient was discharged home 1 month after his initial knee surgery. From the Division of Cardiology, Department of Medicine (D.Y., G.R., P.B., V.B., M.-A.P., J.F., S.L.), and the Division of Cardiothoracic Surgery (O.L.), Emory University School of Medicine, Atlanta, GA; and Piedmont Heart Institute, Piedmont Healthcare, Atlanta, Georgia (R.M.). Reprint requests: Stamatios Lerakis, MD, 1365 Clifton Road NE, Suite AT-503, Atlanta, GA 30322 (E-mail: [email protected]). 0894-7317/$36.00 Copyright 2011 by the American Society of Echocardiography. doi:10.1016/j.echo.2010.05.024
Approximately 2 months later, the patient returned to the hospital because of worsening dyspnea. His blood pressure was initially low but responded to normal saline boluses. Cardiology performed transthoracic echocardiography, which demonstrated a large cavity adjacent to the left ventricle suggestive of an LAA pseudoaneurysm (Figure 1) with bidirectional flow across the defect (Figure 2). Cardiac magnetic resonance imaging was done to confirm and visualize the pseudoaneurysm in greater detail. The pseudoaneurysm measured 9.1 3.7 cm, and the ostium of the defect measured 1.3 cm. On both imaging modalities, it was also clear that flow was bidirectional across the neck of the pseudoaneurysm. After considering the risks involved with an open cardiac procedure due to the patient’s thrombocytopenia, renal failure, and hypercoaguable state (heparin-induced thrombocytopenia), it was decided that the defect would be repaired percutaneously. An Amplatzer septal occluder (AGA Medical Corporation, Plymouth, MN) was chosen to repair the defect. After obtaining informed consent from the patient, he was brought to the hybrid cardiac catheterization room. Vascular access was obtained, and a transseptal needle and sheath were used to perform a transseptal puncture across the interatrial septum. After successfully crossing the septum, a diagnostic catheter was advanced to the level of the LAA, and contrast was injected through the catheter to identify the LAA and defect. After careful review of images, a 14-mm Amplatzer septal occluder was chosen to close the pseudoaneurysm and was advanced to the defect (Figure 3). Once appropriate positioning was confirmed by transesophageal echocardiography and fluoroscopy, the device was deployed and released (Figure 4). Transesophageal echocardiography revealed only mild residual flow through the center of the device after release. Furthermore, echocardiographic ‘‘smoke’’ was visualized in the pseudoaneurysm, suggestive of a dramatic decrease in blood flow. The patient was monitored overnight, and transthoracic echocardiography was performed the following day to assess the closure device and pseudoaneurysm. The device appeared secure, without flow through the neck of the pseudoaneurysm. Furthermore, there was no evidence of flow in the pseudoaneurysm, and it appeared completely thrombosed. However, because of compression of the left ventricle by the large hematoma as well as development of hypotension, the patient was taken to the operating room for a pericardial window with evacuation of the hematoma. Visualization of the pericardial space revealed minimal bleeding at the site of the Amplatzer occluder, and the area was sprayed with a hemostatic adhesive, which 109.e1
109.e2 Yoo et al
Journal of the American Society of Echocardiography January 2011
established excellent hemostasis. The patient was kept in the LAA = Left atrial appendage hospital for a few more days to recover from a suspected hospital acquired pneumonia and a pleural effusion. He was ultimately discharged from the hospital 1 week after his initial presentation. Abbreviation
Figure 3 Three-dimensional transesophageal echocardiographic image revealing placement of the Amplatzer septal occluder across the LAA defect via transseptal puncture. The bioprosthetic mitral valve is also noted. LA, Left atrium; PS, pseudoaneurysm; RA, right atrium. Figure 1 Four-chamber transthoracic echocardiographic image showing a large pseudoaneurysm (PS) adjacent to the left ventricle (LV). LA, Left atrium; RA, right atrium; RV, right ventricle.
Figure 4 Amplatzer septal occluder secured across the defect. AV, Aortic valve; LA, left atrium; PS, pseudoaneurysm.
Figure 2 Transesophageal echocardiographic image revealing bidirectional flow between the LAA and pseudoaneurysm (PS).
DISCUSSION Echocardiographic findings such as those in our case lead to a differential diagnosis that includes rare congenital malformations, atrial dissection with the development of an aneurysm or pseudoaneurysm, and cardiac masses (due to hematoma formation). The specific findings in our case were most consistent with the development of an LAA pseudoaneurysm following cardiac surgery. Our case demonstrates numerous ‘‘firsts’’ in the literature. An extensive review of the literature reveals only a few cases of atrial dissections and pseudoaneurysms following cardiac surgery, none of which involved the LAA. Additionally, the presentation of this complication is usually discovered within days to weeks of the initial surgery, but our patient was asymptomatic for >6 weeks. The long duration prior to presentation may explain the large size of the pseudoaneurysm.
Moreover, routine hemodialysis facilitated the frequent removal of fluid, without which the patient would have succumbed to congestive heart failure much earlier in his course. Traditionally, atrial dissections and pseudoaneurysms are corrected surgically. Because of the high operative risk for our patient with multiple comorbidities, we performed a percutaneous closures of the defect, which is the first known use of a septal occluder device to percutaneously close an atrial pseudoaneurysm.
REFERENCES 1. Gallego P, Oliver JM, Gonzalez A, Dominguez FJ, Sanchez-Recalde A, Mesa JM. Left atrial dissection: pathogenesis, clinical course, and transesophageal echocardiographic recognition. J Am Soc Echocardiogr 2001;14: 813-20. 2. Martinez-Selles M, Garcia-Fernandez MA, Moreno M, Bermejo J, Delcan JL. Echocardiographic features of left atrial dissection. Eur J Echocardiogr 2000;1:147-50. 3. Idir M, Deville C, Roudaut R. Delayed left atrial wall dissection after mitral valve replacement. Echocardiography 2000;17:259-61.
Journal of the American Society of Echocardiography Volume 24 Number 1
4. Heidt MC, Menon AK, Roth P, Mitrev Z, Akintu¨rk HK, Vogt PR. Left atrial dissection after mitral operation mimicking severe mitral regurgitation. J Thorac Cardiovasc Surg 2004;127:596-7. 5. Ninomiya M, Taketani T, Ohtsuka T, Motomura N, Takamoto S. A rare type of left atrial dissection. J Thorac Cardiovasc Surg 2002;124:618-20.
Yoo et al 109.e3
6. Pelias A, Naidech H, Lemole GM, DelRossi AJ. Left atrial pseudoaneurysm (a left atrial catheter complication): a case report. Vasc Endovasc Surg 1986; 20:248-50. 7. Genoni M, Jenni R, Schmid ER, Vogt PR, Turina MI. Treatment of left atrial dissection after mitral repair: internal drainage. Ann Thorac Surg 1999;68:1394-6.
Percutaneous Closure of a Left Atrial Appendage Pseudoaneurysm Dale Yoo, MD, Gregory Robertson, MD, Peter Block, MD, Vasilis Babaliaros, MD, Omar Lattouf, MD, PhD, Maria-Alexandra Pernetz, RDCS, Randolph Martin, MD, Joel Felner, MD, and Stamatios Lerakis, MD, Atlanta, Georgia
Atrial dissections and pseudoaneurysms are rare complications of cardiac surgery. The authors describe the case of a patient after mitral valve replacement who presented with a left atrial appendage pseudoaneurysm. This case represents the first known closure of an atrial pseudoaneurysm with a percutaneous septal occluder device. (J Am Soc Echocardiogr 2011;24:109.e1-109.e3.) Keywords: Pseudoaneurysm, Atrium, Appendage, Percutaneous closure
Atrial dissections and pseudoaneurysms are rare complications of cardiac surgery.1,2 There are few reported cases of such complications in the literature, with most of them revealing themselves within days to weeks of the original surgery and requiring open cardiac repair.3-7 We describe the case of a patient after mitral valve replacement who presented nearly 2 months after surgery with a left atrial appendage (LAA) pseudoaneurysm. Moreover, this case represents the first known closure of a pseudoaneurysm with a percutaneous septal occluder device, usually reserved for patent foramen ovale and atrial septal defects.
CASE PRESENTATION A 53-year-old male with end-stage renal disease presented to the hospital for left knee pain and was diagnosed with villonodular synovitis. Following knee surgery, he became tachycardic and dyspneic, and cardiology was consulted. Transthoracic echocardiography and cardiac magnetic resonance imaging were performed and revealed a vegetation of the anterior leaflet of the mitral valve. Multiple blood cultures were drawn, which remained negative throughout the hospitalization. Because of the severity of the endocarditis, the patient underwent mitral valve replacement with a Medtronic 29-mm Mosaic bioprosthetic valve (Medtronic, Inc, Minneapolis, MN). The native mitral valve was sent to microbiology and all cultures, including fungal, acid-fast bacillus, and bacterial, were negative. Pathology revealed severe necrotizing endocarditis, with purulent inflammation. After a complicated postsurgical course, including ventilator-associated pneumonia and transient sinus node dysfunction with paroxysmal atrial fibrillation, the patient was discharged home 1 month after his initial knee surgery. From the Division of Cardiology, Department of Medicine (D.Y., G.R., P.B., V.B., M.-A.P., J.F., S.L.), and the Division of Cardiothoracic Surgery (O.L.), Emory University School of Medicine, Atlanta, GA; and Piedmont Heart Institute, Piedmont Healthcare, Atlanta, Georgia (R.M.). Reprint requests: Stamatios Lerakis, MD, 1365 Clifton Road NE, Suite AT-503, Atlanta, GA 30322 (E-mail: [email protected]). 0894-7317/$36.00 Copyright 2011 by the American Society of Echocardiography. doi:10.1016/j.echo.2010.05.024
Approximately 2 months later, the patient returned to the hospital because of worsening dyspnea. His blood pressure was initially low but responded to normal saline boluses. Cardiology performed transthoracic echocardiography, which demonstrated a large cavity adjacent to the left ventricle suggestive of an LAA pseudoaneurysm (Figure 1) with bidirectional flow across the defect (Figure 2). Cardiac magnetic resonance imaging was done to confirm and visualize the pseudoaneurysm in greater detail. The pseudoaneurysm measured 9.1 3.7 cm, and the ostium of the defect measured 1.3 cm. On both imaging modalities, it was also clear that flow was bidirectional across the neck of the pseudoaneurysm. After considering the risks involved with an open cardiac procedure due to the patient’s thrombocytopenia, renal failure, and hypercoaguable state (heparin-induced thrombocytopenia), it was decided that the defect would be repaired percutaneously. An Amplatzer septal occluder (AGA Medical Corporation, Plymouth, MN) was chosen to repair the defect. After obtaining informed consent from the patient, he was brought to the hybrid cardiac catheterization room. Vascular access was obtained, and a transseptal needle and sheath were used to perform a transseptal puncture across the interatrial septum. After successfully crossing the septum, a diagnostic catheter was advanced to the level of the LAA, and contrast was injected through the catheter to identify the LAA and defect. After careful review of images, a 14-mm Amplatzer septal occluder was chosen to close the pseudoaneurysm and was advanced to the defect (Figure 3). Once appropriate positioning was confirmed by transesophageal echocardiography and fluoroscopy, the device was deployed and released (Figure 4). Transesophageal echocardiography revealed only mild residual flow through the center of the device after release. Furthermore, echocardiographic ‘‘smoke’’ was visualized in the pseudoaneurysm, suggestive of a dramatic decrease in blood flow. The patient was monitored overnight, and transthoracic echocardiography was performed the following day to assess the closure device and pseudoaneurysm. The device appeared secure, without flow through the neck of the pseudoaneurysm. Furthermore, there was no evidence of flow in the pseudoaneurysm, and it appeared completely thrombosed. However, because of compression of the left ventricle by the large hematoma as well as development of hypotension, the patient was taken to the operating room for a pericardial window with evacuation of the hematoma. Visualization of the pericardial space revealed minimal bleeding at the site of the Amplatzer occluder, and the area was sprayed with a hemostatic adhesive, which 109.e1
109.e2 Yoo et al
Journal of the American Society of Echocardiography January 2011
established excellent hemostasis. The patient was kept in the LAA = Left atrial appendage hospital for a few more days to recover from a suspected hospital acquired pneumonia and a pleural effusion. He was ultimately discharged from the hospital 1 week after his initial presentation. Abbreviation
Figure 3 Three-dimensional transesophageal echocardiographic image revealing placement of the Amplatzer septal occluder across the LAA defect via transseptal puncture. The bioprosthetic mitral valve is also noted. LA, Left atrium; PS, pseudoaneurysm; RA, right atrium. Figure 1 Four-chamber transthoracic echocardiographic image showing a large pseudoaneurysm (PS) adjacent to the left ventricle (LV). LA, Left atrium; RA, right atrium; RV, right ventricle.
Figure 4 Amplatzer septal occluder secured across the defect. AV, Aortic valve; LA, left atrium; PS, pseudoaneurysm.
Figure 2 Transesophageal echocardiographic image revealing bidirectional flow between the LAA and pseudoaneurysm (PS).
DISCUSSION Echocardiographic findings such as those in our case lead to a differential diagnosis that includes rare congenital malformations, atrial dissection with the development of an aneurysm or pseudoaneurysm, and cardiac masses (due to hematoma formation). The specific findings in our case were most consistent with the development of an LAA pseudoaneurysm following cardiac surgery. Our case demonstrates numerous ‘‘firsts’’ in the literature. An extensive review of the literature reveals only a few cases of atrial dissections and pseudoaneurysms following cardiac surgery, none of which involved the LAA. Additionally, the presentation of this complication is usually discovered within days to weeks of the initial surgery, but our patient was asymptomatic for >6 weeks. The long duration prior to presentation may explain the large size of the pseudoaneurysm.
Moreover, routine hemodialysis facilitated the frequent removal of fluid, without which the patient would have succumbed to congestive heart failure much earlier in his course. Traditionally, atrial dissections and pseudoaneurysms are corrected surgically. Because of the high operative risk for our patient with multiple comorbidities, we performed a percutaneous closures of the defect, which is the first known use of a septal occluder device to percutaneously close an atrial pseudoaneurysm.
REFERENCES 1. Gallego P, Oliver JM, Gonzalez A, Dominguez FJ, Sanchez-Recalde A, Mesa JM. Left atrial dissection: pathogenesis, clinical course, and transesophageal echocardiographic recognition. J Am Soc Echocardiogr 2001;14: 813-20. 2. Martinez-Selles M, Garcia-Fernandez MA, Moreno M, Bermejo J, Delcan JL. Echocardiographic features of left atrial dissection. Eur J Echocardiogr 2000;1:147-50. 3. Idir M, Deville C, Roudaut R. Delayed left atrial wall dissection after mitral valve replacement. Echocardiography 2000;17:259-61.
Journal of the American Society of Echocardiography Volume 24 Number 1
4. Heidt MC, Menon AK, Roth P, Mitrev Z, Akintu¨rk HK, Vogt PR. Left atrial dissection after mitral operation mimicking severe mitral regurgitation. J Thorac Cardiovasc Surg 2004;127:596-7. 5. Ninomiya M, Taketani T, Ohtsuka T, Motomura N, Takamoto S. A rare type of left atrial dissection. J Thorac Cardiovasc Surg 2002;124:618-20.
Yoo et al 109.e3
6. Pelias A, Naidech H, Lemole GM, DelRossi AJ. Left atrial pseudoaneurysm (a left atrial catheter complication): a case report. Vasc Endovasc Surg 1986; 20:248-50. 7. Genoni M, Jenni R, Schmid ER, Vogt PR, Turina MI. Treatment of left atrial dissection after mitral repair: internal drainage. Ann Thorac Surg 1999;68:1394-6.