Brown Kristen N., Singh Rahulkumar
Augusta University
Texas Health Arlington Memorial Hospital
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.
左心室假性动脉瘤（LVP）是心肌梗死、心脏手术、外伤和感染后一种非常罕见但致命的并发症。LVP的特征是左心室壁破裂，由心包或瘢痕组织包裹。LVP患者可出现充血性心力衰竭、心律失常。左心室破裂后发生心包填塞通常是致命的。卡萨波等人报告LVP的发病率约为0.29%（《临床心脏病学》，1997年）。研究表明，在所有导致LVP的原因中，心肌梗死和心脏手术分别占55%和33%。在心脏手术中，二尖瓣置换术后LVP的发生率较高。传统上，左心室假性动脉瘤的首选治疗方法是紧急手术干预。手术本身的死亡率很高，在20%至36%之间，但最近的一些研究表明死亡率已降至10%。[然而，由于风险高而无法考虑手术且首选药物治疗的病例，死亡率甚至更高，接近48%左右。但在过去二十年左右的时间里，经导管手术方法的改进和先进的设备技术使经皮封堵LVP成为一种越来越可行的选择，特别是对于手术预后不佳的患者。2004年，克利夫特等人首次描述了经皮封堵左心室假性动脉瘤。2016年，奥山及其同事在经导管主动脉瓣置换术后，经心尖途径成功完成了第一例经皮封堵治疗（PTC）。在此之前，文献报道的大多数病例是在危及生命的心肌梗死后通过手术进行的。目前尚无关于LVP经导管治疗的大型研究，但已有多项成功的病例研究报道，证明了其未来的潜力。也有一些关于混合治疗方法的报道，即先用LVP的PTC在紧急情况下稳定患者，然后进行金标准的手术闭合。本文将详细讨论左心室假性动脉瘤的解剖结构、LVP的潜在病因、PTC的适应证、PTC的禁忌证、PTC技术、PTC可能的并发症以及PTC手术出现的临床意义。
