Left Ventricular Pseudoaneurysm
A Late Complication of Low-Energy DC Ablation
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 3×4-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.
The online-only Data Supplement, which contains 2 movies, is available at http://circ.ahajournals.org/cgi/content/full/113/21/e780/DC1.