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• W2023556973 abstract "Transcatheter aortic valve implantation by an apical approach has been developed as an alternative to conventional aortic valve replacement. Complications with these relatively new procedures are being reported. We report a case of transapical transcatheter aortic valve implantation, in which a pseudoaneurysm at the apex of the left ventricle as a complication of the procedure developed in the patient and was treated without surgery. The defect spontaneously closed. Transcatheter aortic valve implantation by an apical approach has been developed as an alternative to conventional aortic valve replacement. Complications with these relatively new procedures are being reported. We report a case of transapical transcatheter aortic valve implantation, in which a pseudoaneurysm at the apex of the left ventricle as a complication of the procedure developed in the patient and was treated without surgery. The defect spontaneously closed. Transapical aortic valve implantation (TAVI) is a novel approach recognized as a viable therapeutic option for patients with severe symptomatic aortic stenosis and who are high risk for conventional surgery [1Masson J.-B. Kovac J. Schuler G. et al.Transcatheter aortic valve implantation: review of the nature, management and avoidance of procedural complications.J Am Coll Cardiol Intv. 2009; 2: 811-820Abstract Full Text Full Text PDF Scopus (367) Google Scholar]. As demonstrated in patients who were not suitable candidates for surgery (compared with standard therapy), TAVI has significantly reduced the rates of death from any cause, and has reduced repeat hospitalization and cardiac symptoms, despite the higher incidence of major strokes and vascular events [2Leon M.B. Smith C.R. et al.PARTNER Trial InvestigatorsTranscatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery.N Engl J Med. 2010; 363: 1597-1607Crossref PubMed Scopus (5249) Google Scholar]. An intraoperative or postoperative complications rate of 18.8% has been reported in some articles [3Pasic M. Buz S. Dreysse S. et al.Transapical aortic valve implantation in 194 patients: problems, complications, and solutions.Ann Thorac Surg. 2010; 90: 1463-1470Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar]. One of the possible complications of the transapical technique is the appearance of left ventricular pseudoaneurysm (LVP), mainly in patients with a fatty apex. Nevertheless, the rate of LVP is approximately 1% [3Pasic M. Buz S. Dreysse S. et al.Transapical aortic valve implantation in 194 patients: problems, complications, and solutions.Ann Thorac Surg. 2010; 90: 1463-1470Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar] to 6.6% [4Wong D.R. Ye J. Cheung A. et al.Technical considerations to avoid pitfalls during transapical aortic valve implantation.J Thorac Cardiovasc Surg. 2010; 140: 196-202Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar], and a very low number of cases have been published in the recent literature [1Masson J.-B. Kovac J. Schuler G. et al.Transcatheter aortic valve implantation: review of the nature, management and avoidance of procedural complications.J Am Coll Cardiol Intv. 2009; 2: 811-820Abstract Full Text Full Text PDF Scopus (367) Google Scholar, 3Pasic M. Buz S. Dreysse S. et al.Transapical aortic valve implantation in 194 patients: problems, complications, and solutions.Ann Thorac Surg. 2010; 90: 1463-1470Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar, 5Elhenawy A. Rocha R. Feindel C.M. Brister S.J. Persistent left ventricular false aneurysm after transapical insertion of an aortic valve.J Card Surg. 2011; 26: 51-53Crossref PubMed Scopus (12) Google Scholar, 6Al-Attar N. Ghodbane W. Himbert D. et al.Unexpected complications of transapical aortic valve implantation.Ann Thorac Surg. 2009; 88: 90-94Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar]. We present a case of a 75-year-old man who is diabetic, with severe chronic obstructive pulmonary disease, mild renal insufficiency, chronic atrial fibrillation, coronary artery disease with two bare metal stents, implanted 3 years ago, and Heyde syndrome with colonic angiodysplasia. He was referred to our center due to a severe aortic stenosis with a mean echocardiographic gradient of 56 mm Hg. Because of his comorbidities and a logistic EuroSCORE of 12.24%, with a Society of Thoracic Surgeons' score of 19.5%, TAVI was decided to be the best option for treatment. A 26-mm Edwards Sapien (Edwards Lifesciences Inc, Irvine, CA) transcatheter heart valve was introduced by a conventional transapical approach (26-French Ascendra catheter; Edward Lifesciences Inc) without surgical incidences. Our technique for transapical TAVI is briefly described as follows: a 6-French pigtail was positioned in the ascending aorta through a femoral approach, and a temporary pacemaker was placed in the right ventricle. After the localization of the apex by echocardiography, we performed a left mini-thoracotomy, and two apical pursestring sutures reinforced with pledgets were placed. Then we punctured the apex with a needle and passed the 0.035 soft hydrophilic wire (Terumo Inc, Tokyo, Japan) and a JR4 diagnostic catheter (Cordis Corporation, Miami, FL) was tracked in the ascending aorta, crossing the arch down to the abdominal aorta. At this point, the soft hydrophilic wire was changed for an Amplatz super stiff guidewire (Boston Scientific, Natick, MA). Aortic valvuloplasty was performed during right ventricular pacing (200 bpm) using a Nucleus 25/40-mm balloon (NuMed, Inc, Hopkinton, NY); the 26-mm aortic prosthesis (Edwards Sapien TM THV [Edwards Lifesciences, Inc]) was positioned across the native valve and was deployed under fluoroscopic guidance. Three hours later, an emergent surgical intervention was necessary due to massive bleeding. The origin was detected from the apex, secondary to suture dehiscence, after digital control of the bleeding zone in which we applied two new pursestring sutures that successfully controlled the bleeding. After that, the patient was discharged with an unremarkable recovery in 13 days. Six months later, he was referred again to our institution due to mild bleeding from the previous surgical incision. A computed tomographic scan showed an LVP with a defect of 30 × 50 mm (Fig 1). The patient refused an emergent procedure and was self-discharged without anticoagulant therapy and expectant conservative management. Six months later the LVP was completely thrombosed, with complete spontaneous closure of the defect (Fig 2).Fig 2Computed tomographic scan at 6 months shows a complete left ventricular pseudoaneurysm thrombosis and closure.View Large Image Figure ViewerDownload (PPT) A transapical approach for TAVI access to the left ventricular cavity is obtained by a needle puncture near the apex. Post-procedural, low-grade bleeding from the access site might result in cardiac tamponade and require further repair. In our case, an emergent surgical intervention was necessary due to massive bleeding and repair was carried out. The LVP has been reported, but it is infrequent [5Elhenawy A. Rocha R. Feindel C.M. Brister S.J. Persistent left ventricular false aneurysm after transapical insertion of an aortic valve.J Card Surg. 2011; 26: 51-53Crossref PubMed Scopus (12) Google Scholar]. In rare cases, and in this procedure, a pseudoaneurysm formation at the site of ventricular puncture or repair has been observed weeks to months after TAVI. Although pseudoaneurysms might be initially be asymptomatic, they are typically progressive and might require new surgical intervention [1Masson J.-B. Kovac J. Schuler G. et al.Transcatheter aortic valve implantation: review of the nature, management and avoidance of procedural complications.J Am Coll Cardiol Intv. 2009; 2: 811-820Abstract Full Text Full Text PDF Scopus (367) Google Scholar]. In this case, the patient returned to the hospital due to mild bleeding from the previous surgical incision. According to the low number of cases in current literature for this complication, we decided on an emergent LVP repair, but the patient rejected the surgery. Evolution was satisfactory with a spontaneous closure of the defect 6 months after diagnosis with conservative management. Most published articles describing this complication have been treated by surgery, even using cardiopulmonary bypass and deep hypothermic circulatory arrest [3Pasic M. Buz S. Dreysse S. et al.Transapical aortic valve implantation in 194 patients: problems, complications, and solutions.Ann Thorac Surg. 2010; 90: 1463-1470Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar, 4Wong D.R. Ye J. Cheung A. et al.Technical considerations to avoid pitfalls during transapical aortic valve implantation.J Thorac Cardiovasc Surg. 2010; 140: 196-202Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar, 5Elhenawy A. Rocha R. Feindel C.M. Brister S.J. Persistent left ventricular false aneurysm after transapical insertion of an aortic valve.J Card Surg. 2011; 26: 51-53Crossref PubMed Scopus (12) Google Scholar, 6Al-Attar N. Ghodbane W. Himbert D. et al.Unexpected complications of transapical aortic valve implantation.Ann Thorac Surg. 2009; 88: 90-94Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar]. In conservative management cases, satisfactory outcomes were obtained [4Wong D.R. Ye J. Cheung A. et al.Technical considerations to avoid pitfalls during transapical aortic valve implantation.J Thorac Cardiovasc Surg. 2010; 140: 196-202Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar]. In summary, we present an unusual case of late onset LVP after TAVI. After a period of 6 months, we observed a spontaneous closure without requiring surgery. This case may raise doubts as to which the best management is in asymptomatic LVP after TAVI, due to surgical high risk and good outcomes showed in literature with conservative management. Special care must be taken in fatty and friable apex due to the high risk of complications." @default.
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• W2023556973 title "Spontaneous Closure of Pseudoaneurysm After Transapical Aortic Valve Implantation" @default.
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