Canadian Journal of Cardiology

Challenging Transcatheter Treatment of a “Complex” Refractory Congestive Heart Failure

Published:December 13, 2019DOI:
      A 61-year-old man with a history of postischemic dilated cardiomyopathy was referred in advanced congestive heart failure to our department (Department of Cardiology). He had a history of acute inferolateral myocardial infarction complicated by left ventricular (LV) aneurysm treated elsewhere by coronary artery bypass grafts, aneurysm resection, and automatic implantable cardioverter defibrillator implantation a few years before. At the time of admission, he was in functional New York Heart Association class III-IV with signs and symptoms of congestive heart failure and low cardiac output. At echocardiography, left cardiac chamber enlargement and severe LV hypokinesis (ejection fraction < 30% by Simpson method) were imaged. The LV was compressed and distorted by a huge pseudoaneurysm located between the inferior and posterior-lateral wall, resulting in severe mitral valve regurgitation (Fig. 1A). On the computed tomography scan, the site and size (11.8 × 6 cm) of the LV pseudoaneurysm were better detailed (Fig. 1B). Because of the perceived high surgical risk, a 2-step percutaneous treatment was planned. First, the pseudoaneurysm was imaged (Fig. 1C) and probed from the aortic route. Then, its mouth was carefully sized with an Equalizer Occlusion balloon (Boston Scientific, Cork, Ireland) and occluded by implantation of a 28-mm Amplatzer septal occluder device (Abbott, Plymouth, MN) (Fig. 2A, Video 1 , view video online) under transesophageal echocardiography guidance. Two months later, the mitral valve regurgitation was treated by sequential implantation of 3 MitraClip devices (Abbott Vascular, Santa Clara, CA) with a standard technique under 3-dimensional transesophageal echocardiography guidance. At the end of the procedures, no flow into the aneurysmal sac and just mild mitral regurgitation were imaged (Fig. 2B, Video 2 , view video online). At the 6-month follow-up evaluation, the patient was asymptomatic and in functional New York Heart Association class I-II under mild antifailure therapy.
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      Figure 1Transthoracic echocardiographic imaging (A) of severe mitral valve regurgitation (arrow). (B) Computed tomography scan showing a huge pseudoaneurysmal sac located at the left ventricular (LV) inferolateral aspect. (C) Angiographic evaluation of the LV pseudoaneurysm. LA, left atrium; LV, left ventricle; PA, pseudo-aneurysm.
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      Figure 2(A) LV angiography after implantation of an atrial septal occluder device (asterisk) inside the pseudoaneurysmal sac. (B) Mild residual mitral valve regurgitation, as imaged after the pseudoaneurysm closure and implantation of multiple MitraClip devices (Abbott Vascular, Santa Clara, CA) (arrow). LA, left atrium; LV, left ventricle.
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