Percutaneous Closure of a Left Ventricular Free-Wall Rupture Site
An 86-year-old woman who lived independently was referred for consideration of percutaneous closure of a left ventricular free wall rupture site. Ten years earlier, she had undergone aortic valve replacement with a Carpentier-Edwards bioprosthesis (Edwards Lifesciences, Irvine, Calif) and received a single saphenous vein graft to the right coronary artery. Five years later, at the age of 81, she had an inferolateral myocardial infarction and an acute rupture of the left ventricular free wall. The resultant false aneurysm appeared to be small and contained (because of adhesions) and was managed conservatively.
Over the subsequent 4 years, she had increasing symptoms of heart failure with several hospital admissions, and there was radiographic (Figure, A) and echocardiographic evidence of increasing size of the false aneurysm, with dimensions of 6.5×4.5×8.5 cm (Figure, E). It had a focal neck, measuring 8 mm in diameter.
Cardiac catheterization was undertaken and a left ventricular angiogram was performed (Figure, B), demonstrating a large, calcified, egg-shaped false aneurysm with a narrow neck. Closure of the defect was then successfully undertaken with the patient under local anesthesia, using transthoracic echocardiographic guidance and fluoroscopy. A 12-mm Amplatzer septal occluder (AGA Medical Corporation, Golden Valley, Minn) was deployed through an 8F delivery sheath and advanced into the false aneurysm retrogradely from the right femoral artery, crossing the bioprosthetic aortic valve. A subsequent angiogram showed the defect to be successfully occluded with only a trivial residual leak (Figure, C and D), which had completely sealed on echocardiography (Figure, G and H). This report describes a rare combination of circumstances that permitted successful percutaneous treatment.