Transcatheter Management of Left Ventricular Pseudoaneurysms

Left ventricular pseudoaneurysms (LVP) is a very rare but lethal complication of myocardial infarction, cardiac surgery, trauma, and infection.   LVP is characterized by left ventricle wall ruptures and is contained by pericardium or scar tissue. Patients with LVP can present with congestive heart failure, arrhythmias. Development of tamponade after left ventricular rupture is usually fatal. Casapo et al reported the incidence rate of LVP at around 0.29% (Clin Cardiol 1997). Studies suggest that, of all causes of LVP, myocardial infarction and cardiac surgery results in 55% and 33% respectively. In cardiac surgery, Mitral Valve replacement is associated with a higher rate of LVP. Traditionally, the preferred management of a left ventricular pseudoaneurysm has been emergency surgical intervention. The surgery itself has high mortality ranging from 20-36% but some of the recent studies have shown improvement in mortality to 10 %. [   However cases, where surgery cannot be considered because of high risk and medical management is preferred, mortality is even high and its close to around 48 %. But in last two decade or so, enhanced transcatheter procedural approaches and advanced device technology has made the percutaneous closure of LVP an increasingly practical option, especially in a patient with an unfavorable predicted surgical outcome. Percutaneous closure of the left ventricular pseudoaneurysm was first described by Clift et al10 in 2004. In 2016, Okuyama and colleagues performed the first case of a PTC successfully following transcatheter aortic valve replacement using trans-apical access. Before that, most cases reported in the literature were performed via surgery following life-threatening myocardial infarctions. There is no large study on the transcatheter management of LVP but multiple successful case studies have been reported which vouch for its future potential. There are also some reports of a hybrid approach which uses the PTC of the LVP to first stabilize the patient during the emergency setting followed by the gold standard surgical closure. This article will discuss in detail the anatomy of a left ventricular pseudoaneurysm, potential etiologies of LVP, indications for PTC, contraindications for PTC, the technique of PTC, possible complications of PTC, and the clinical significance of the advent of the PTC procedure.