Successful Closure of an Aortic Pseudoaneurysm and Mitral Paravalvular Leak Via a Hybrid Transapical Approach

This video shows a case of successful closure of an aortic pseudoaneurysm and mitral paravalvular leak via a hybrid transapical approach.

The Patient

The patient is a sixty-year-old man who was born with coarctation of the aorta and a bicuspid aortic valve. At age ten, he underwent repair of his coarctation via a left thoracotomy without any residual coarctation or aneurysm. At age twenty-five, he developed bicuspid valve endocarditis, which ultimately required mechanical aortic and mitral valve replacement.

At age forty-eight, he subsequently developed a large aortic root versus left ventricular outflow tract pseudoaneurysm and a mitral paravalvular leak. During initial workup at an outside facility, his pseudoaneurysm and paravalvular leak were surveilled and felt to be stable in size, and thus—given the risks of surgical intervention—he elected not to opt for surgical repair. The patient subsequently developed atrial fibrillation and heart failure with reduced ejection fraction (EF 30-35%), and ultimately underwent cardioversion with improvement in his ejection fraction.

At age fifty-nine, his pseudoaneurysm showed enlargement to 5.5 x 5.6 x 4.8 cm on a CTA. In addition, his mitral paravalvular leak had grown to 1 x 0.6 cm with at least moderate mitral regurgitation. 3D reconstruction also demonstrated the mitral defect. Given the degeneration in his pathology, he was referred for consideration of percutaneous versus surgical treatment of the above.

Ultimately, the patient and the heart team, including the cardiothoracic surgery and interventional cardiology team, elected to pursue a less invasive approach than traditional median sternotomy given the complexity and morbidity that would be associated with open repair.

The Plan

Preoperative 3D modeling was used to further delineate pathology and optimize procedural approach. The 3D modeling suggested the aortic pseudoaneurysm traversed the valve annulus, and thus it could not be identified whether it was above or below the valve annulus. In regard to the mitral pathology, the transeptal approach would not be feasible because of the tight angle, and the pathology could not be addressed via transfemoral approach because of the mechanical aortic valve and the inability to pass a sheath through it. As a whole, it was felt that addressing the mitral leak would require a transapical approach or an open surgery. In regard to the aortic pathology, if it was above, it would be addressed via transfemoral approach, and if below via transapical approach.

Using the preoperative imaging information available as well as a multidisciplinary team, surgeons created an algorithm of approach for the procedure. Surgeons felt it would be most important to address the aortic pathology given the significant risk of mortality it carried. The team would start by attempting to identify the location of the aortic pseudoaneurysm tract using TEE. If that was unsuccessful, the team would obtain transfemoral access for angiography to further delineate its location. If the defect was above the annulus, surgeons would elect to only fix the aortic pathology, given that it could be fixed via transfemoral approach, and the mitral pathology would require transapical access and a thoracotomy. If the defect was below the annulus, the aortic pseudoaneurysm would be best addressed via transapical approach, and thus the team would attempt to manage both the aortic and mitral pathology via the transapical approach. If it was above and below the annulus, a hybrid of transfemoral and transapical access would be used. If any of the above failed or if the patient became hemodynamically unstable, the team would proceed to a sternotomy, the most morbid approach.

The Surgery

Subsequently, the patient was taken to the operating room and initial TEE could not delineate whether filling defect was above or below the aortic annulus. 3D reconstruction of the aorta also could not identify the location of the defect; however, it could be seen clearly that there was flow into the pseudoaneurysm.

At that point in time, femoral access was obtained. An aortogram was performed and demonstrated no antegrade filling of the pseudoaneurysm above the valve.

Next, a left anterolateral thoracotomy was performed with opening of the chest at the sixth interspace. The pericardium was opened and the apex of the left ventricle (LV) was identified visually and by echocardiogram. Two purse string sutures was placed, the suture was secured in red rubber catheters, and heparin was given to obtain an ACT > 250. The apex was then accessed, and an 8 French sheath was placed.

Through the transapical access, an LV gram was performed, identifying a paravalvular defect at the aortic annulus with a large pseudoaneurysm. A wire was then advanced into the defect. An additional angiogram was then performed to confirm catheter placement within the pseudoaneurysm, again demonstrating that the defect was below the annulus.

Next, using the transapical access, a 10mm AVP2 plug was advanced into the pseudoaneurysm. The vascular plug was then deployed with the first disc within the pseudoaneurysm. At this point, the team was reassured from the earlier deployment, as there was static contrast within the pseudoaneurysm. The catheter itself, in addition to the previously placed plugs, seemed to prevent contrast from washing out.

Therefore, the final disc was deployed at the base of the pseudoaneurysm at the paraventricular outflow tract with careful manipulation to ensure there was sufficient distance from the mechanical aortic valve and from the hinge point of the mechanical leaflets.

A repeat angiogram demonstrated that flow was completed occluded into the pseudoaneurysm, with some residual contrast still present within it. Repeat echocardiography confirmed total occlusion of the pseudoaneurysm tract with no flow within it. In addition, the density of the contrast could be seen pooling at the inferior aspect of the pseudoaneurysm, also suggesting exclusion.

The mitral defect was then addressed. A variety of catheters were used before the team was able to successfully get across the mitral defect given the tight angle required to get across it. Correct placement was confirmed by angiogram and by TEE 3D reconstruction.

A 6 mm AVP2 plug was placed in the paravalvular defect and the second disc of the AVP2 plug was deployed. Following plug placement, a significant reduction in flow was seen across the defect by echocardiogram, and 3D reconstruction confirmed resolution of the mitral defect.

The sheath was then withdrawn, and the transapical access site was closed using the previously placed purse-string sutures with pledgets.

A 24 French chest tube was placed in the left pleural space, hemostasis was ensured, and the thoracotomy was closed with paracostals, followed by a layered closure, and finished with a running subcuticular stitch.

Convalescence thereafter was uncomplicated. The patient was discharged on postoperative day six, with no aortic or mitral regurgitation on TTE. Repeat CTA prior to discharge demonstrated complete exclusion of the aortic pseudoaneurysm.

Conclusions

There are a number of important points to take away from this case. First, preoperative planning is important, and a multidisciplinary approach can be helpful in addressing complex pathology. This is not just limited to surgeons and interventionalist, but also to imaging scientists, echocardiographers, and anesthesiologists, who can assist in optimizing approach. Additionally, for the treatment of complex pathology, a procedural algorithm of approach is essential. In this case, the initial less invasive transfemoral access which demonstrated that there was no defect above the annulus helped determine the next step of obtaining transapical access. Lastly, although endovascular approaches can be challenging and can require a lot of patience to obtain optimal access, they offer significantly less morbid alternatives to open surgery and can provide an excellent outcome. Most importantly, the patient is doing well three months postoperatively. He is active, without symptoms, and overall living an excellent quality of life.

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