Percutaneous Closure of a False Aneurysm of the Right Ventricle in a Congenital Heart Disease Patient
A 25-year-old man with pulmonary atresia and ventricular septal defect had a right and a left Blalock Taussig shunt during infancy. At the age of 12 he had a 3rd surgical operation, consisting of unifocalization of systemic collateral arteries to the right lung, and complete intracardiac repair by ventricular septal defect closure and interposition of a 25 mm homograft between the infundibulum and the pulmonary trunk. No complications were observed in the postoperative period. The patient led a normal life for 13 years, but after this period he started to refer dyspnea at exercise. There was no evidence of active or previous infection.
At clinical examination the patient was in good general condition and had a systolic murmur on the left sternal border. At chest x-ray, cardiothoracic ratio was 0.6, a pronounced pulmonary arch was noticed and calcifications were present at the junction of the right ventricle to the pulmonary artery (Figure 1). Transthoracic echocardiography showed a normal left ventricle and a hypertrophied and dilated right ventricle with normal systolic function. There was a trivial obstruction to the right ventricular outflow, and right ventricular pressure could be estimated at 40 mm Hg on the basis of a mild tricuspid regurgitant jet. The homograft could not be analyzed because the anomalies of the right ventricular outflow tract to the pulmonary artery junction were not visible, thus a computed tomography scan was planned.
Multislice computed tomography scan showed extensive calcification of the homograft and a dehiscence at its proximal insertion. A large, partially organized false-aneurysm measuring 8×6 cm was identified (Figure 2).
Cardiac catheterization was undertaken in order to exclude the aneurysm by using a covered stent. Right ventricular pressure was 50/0/10, pulmonary pressure was 40/15/25; the presence of a large calcified egg–shaped false aneurysm with a large neck at the proximal insertion of the homograft was confirmed (Figure 3A). The large size of the infundibulum did not allow the deployment of a covered stent. The aneurysm had a focal neck, measuring 20 mm. While the patient was under waking sedation, using transthoracic echocardiographic guidance and fluoroscopy, a long sheath was advanced into the aneurysm and a 20 mm Amplatzer septal occluder (AGA Medical Corporation, Golden Valley, Minn) was deployed into the false aneurysm (Figure 3B).
Final angiogram showed that the defect was successfully occluded with only trivial residual shunt (Figure 3C).
Computed tomography scan, performed the same day, showed good device positioning and persistence of a mild shunt (Figure 4).
The patient was discharged the day after the procedure and at 2 month follow-up, he is symptom-free. Coil occlusion of the residual shunt will be considered.
Recently, Gladding et al1 reported the percutaneous closure of a left ventricular free-wall rupture site using an Amplatzer device in an 86-year-old woman. Percutaneous treatment could be a reasonable option to surgery in selected, high–risk patients. Our report offers new perspectives to percutaneous treatment of rare complications in multioperated patients with congenital heart disease.