Percutaneous closure of a giant left ventricular pseudoaneurysm using an Amplatzer muscular VSD occluder in a high-risk patient with recurrent heart failure following multiple myocardial infarctions

Figures

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  Figure 1. Pre-procedural transthoracic echocardiographic assessment of the left ventricular pseudoaneurysm. A, Apical view with color Doppler demonstrates the high-velocity flow jet (red arrow) traversing the narrow neck into the pseudoaneurysmal cavity, with an orifice diameter of 1.3 cm. B, Two-dimensional imaging shows the pseudoaneurysmal sac (red arrow) located adjacent to the lateral-to-posterolateral wall of the left ventricle. C, Quantitative volumetric analysis of the pseudoaneurysmal cavity (red arrow) reveals an end-systolic volume of 54–57 mL and a long-axis dimension of 9.6 cm, with active dynamic emptying-and-filling between cardiac cycles. D, Three-dimensional volume-rendered image (red arrow) provides spatial appreciation of the pseudoaneurysm geometry.

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  Figure 2. Pre-procedural imaging and initial procedural steps. A, Pre-procedural left ventriculography demonstrates contrast opacification of the pseudoaneurysmal cavity (red arrow) through a narrow neck arising from the lateral wall. B, Cardiac magnetic resonance imaging confirms the giant pseudoaneurysm (red arrow) arising from the lateral-to-posterolateral wall. C, Intraprocedural fluoroscopy shows retrograde crossing of the orifice with a 0.035-inch guidewire (red arrow) advanced into the pseudoaneurysmal cavity. D, After exchange for a stiff support wire, an 8 F Flexor introducer sheath (red arrow) is advanced across the orifice into the pseudoaneurysmal lumen.

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  Figure 3. Sequential steps of device deployment. A, The distal disc of the Amplatzer Muscular VSD Occluder (red arrow) is unsheathed within the pseudoaneurysmal cavity. B, The proximal disc (red arrow) is opened on the ventricular side, sandwiching the orifice between the two retention discs. C, The device (red arrow) is released from the delivery cable, demonstrating stable positioning across the orifice. D, Final left ventriculography confirms successful closure with no contrast extravasation into the pseudoaneurysmal cavity (red arrow).

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  Figure 4. Post-procedural assessment confirming successful closure. A, Fluoroscopy after device deployment demonstrates the Amplatzer Muscular VSD Occluder (red arrow) in stable position across the orifice with no contrast extravasation. B, Post-procedural transthoracic echocardiography shows the device (red arrow) in stable position with progressive thrombosis of the pseudoaneurysmal sac and absence of residual flow.