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(Circulation. 2006;113:e780-e781.)
© 2006 American Heart Association, Inc.

Images in Cardiovascular Medicine

Left Ventricular Pseudoaneurysm

A Late Complication of Low-Energy DC Ablation

Fadi Mansour, MD; Arsène J. Basmadjian, MD; Denis Bouchard, MD; Reda Ibrahim, MD; Peter G. Guerra, MD; Paul Khairy, MD, PhD

From the Departments of Cardiology and Cardiac Surgery, Montreal Heart Institute, Montreal, Canada.

Correspondence to Dr Paul Khairy, Electrophysiology and Adult Congenital Heart Disease, Montreal Heart Institute, 5000 Belanger Street E, Montreal, Quebec, Canada, H1T 1C8. E-mail paul.khairy{at}cardio.chboston.org

A 50-year-old man had undergone transcatheter low-energy DC ablation for symptomatic Wolff-Parkinson-White syndrome at 35 years of age. By a retrograde aortic approach, a left lateral bidirectional accessory pathway had been ablated with 7 pulsed 20-J shocks through a 7F quadripolar deflectable catheter (Mansfield-Webster, Watertown, Mass). This catheter was connected to a custom-made box incorporating a high-tension relay, allowing for the delivery of anodal shocks while simultaneously recording intracardiac electrograms and surface ECG leads. The indifferent electrode consisted of a large patch positioned under the left scapula. During each shock, a 4-channel, 8-bit digital storage oscilloscope (No. 1604, Gould Inc, Glen Burnie, Md) recorded voltage and current over time. The procedure was acutely successful, well tolerated, and without apparent complication. A predischarge echocardiogram was unremarkable.

After a 15-year hiatus, the patient presented with syncope. Echocardiography revealed a 3x4-cm pseudoaneurysm at the base of the left ventricular lateral wall under the mitral annulus (Figure 1). The cavity was free of thrombus, had systolic and diastolic flow, and had a narrow, 3-mm neck representing 7.5% of its total diameter (Data Supplement Movie I). Cardiac magnetic resonance imaging (Figure 2 and Data Supplement Movie II) confirmed the left ventricular cavity to be a pseudoaneurysm with a partially calcified thin wall. The pseudoaneurysm mildly compressed adjacent structures, including the left atrium and left inferior pulmonary vein, and displaced the left coronary circumflex artery. An exercise stress test was electrically positive, and myocardial perfusion scintigraphy revealed mild inferoposterolateral ischemia. Coronary angiography demonstrated a corresponding 35% to 40% dynamic systolic obstruction of the left circumflex artery. The pseudoaneurysm was surgically resected by a transaneurysmal approach with oversewing of the neck.

View larger version (53K): [in this window] [in a new window]   Figure 1. Transthoracic echocardiographic apical 4-chamber view of the left ventricular pseudoaneurysm. A, Left ventricular pseudoaneurysm (3x4 cm) is indicated by white arrows. B, Color Doppler imaging displays the neck of the pseudoaneurysm at the lateral margin of the mitral annulus. Flow into the pseudoaneurysm during systole is illustrated.

View larger version (105K): [in this window] [in a new window]   Figure 2. Cardiac magnetic resonance imaging of the left ventricular pseudoaneurysm (echo time 40, echo-train length 32, 7.0-mm thickness, 2.0-mm skip space; matrix, 256x192; displayed field of view, 33.9x33.9 cm; Torso coil, General Electric, 1.5 Tesla). A, Long-axis, double-inversion recovery image acquired during breath-holding is depicted. The neck of the pseudoaneurysm, indicated by the arrow, is in a left lateral position at the site of DC ablation. B, Partially calcified pseudoaneurysm is seen in axial view.

	Acknowledgments

 
Disclosures

None.

	Footnotes

 
The online-only Data Supplement, which contains 2 movies, is available at http://circ.ahajournals.org/cgi/content/full/113/21/e780/DC1.

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Issue Highlights
Circulation 2006 113: 2473. [Full Text]

This Article Full Text (PDF) Data Supplement Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Mansour, F. Articles by Khairy, P. Search for Related Content PubMed PubMed Citation Articles by Mansour, F. Articles by Khairy, P. Related Collections Electrophysiology Ablation/ICD/surgery CT and MRI Related Article