PMC8419236_01
Transesophageal echocardiogram (TEE). 2D imaging showing the paravalvular pseudoaneurysm (yellow arrows) protruding in diastole into the left ventricle outflow tract (A,B). 2D (C) and 3D (D,E) TEE color Doppler showing the paravalvular pseudoaneurysm (white arrows) protruding in diastole into the left ventricle outflow tract and the paravalvular pseudoaneurysm fistula causing severe regurgitation. LV, left ventricle; LA, left atrium; PP, paravalvular pseudoaneurysm; PPF, paravalvular pseudoaneurysm fistula.
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Two-dimensional and three-dimensional (2D/3D) transesophageal echocardiography (TEE) showed a well-functioning bioprosthetic valve and a PPF protruding in diastole into the left ventricle outflow tract with severe PVL (Figures 1A-E). A silicone-printed 3D heart model was made based on MDCT reconstruction (Figure 2B, Supplementary Figure 1)to better understand PPF anatomy and its relationship with the surrounding structures and for planning "ex vivo" transcatheter implantation of the most appropriate occluding device (Figure 2C).
Multidetector computed tomography angiography (MDCTA) scans (A) with acquired frames in systolic (a,c) and diastolic phase (b,d) confirming the presence of the paravalvular pseudoaneurysm fistula located at the left coronary cusp in close proximity of the left main coronary artery (yellow star) and protruding in diastole into the left ventricle outflow tract (red arrow). Silicone printed 3D heart model made on the basis of MDCTA scan reconstruction (B). Silicone 3D model seen from the left ventricle outflow tract (upper panels) and from the ascending aorta (bottom panels) and used to mimic the implantation of a self-expanding double-disc 5-mm square twist Occlutech PLD, with a distal left ventricle disc of 10 mm and a proximal aortic disc of 8.5 mm. Note that the device does not impinge on the bioprosthetic aortic valve (red star). RCC, right coronary cusp; LCC, left coronary cusp; NCC, non-coronary cusp; RCA, right coronary artery; LMCA, left main coronary artery; LAD, left anterior descending; LVOT, left ventricle outflow tract.
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Multidetector computed tomography (MDCT) (Figure 2A) confirmed the PPF location under the left coronary cusp close to the left main coronary artery ostium. A silicone-printed 3D heart model was made based on MDCT reconstruction (Figure 2B, Supplementary Figure 1)to better understand PPF anatomy and its relationship with the surrounding structures and for planning "ex vivo" transcatheter implantation of the most appropriate occluding device (Figure 2C). Based on the measurements made with TEE and angiography, a bigger PDL (10 x 4 mm), different both in shape (rectangular) and in type of connection (waist), with a 19-mm distal LV disc and 17-mm proximal aortic disc was advanced into the LV (Figure 4D; Supplementary Figure 2) and deployed under continuous fluoroscopic, angiographic and 2D/3D TEE guidance.
Intraprocedural transesophageal echocardiogram (A). 2D X-plane imaging (upper panels) and 3D (bottom line) with measurements of the paravalvular pseudoaneurysm fistula. Preprocedural ascending aorta angiogram and volume-rendering three-dimensional (3D) multidetector computed tomography angiography (MDCT) (B) showing the paravalvular pseudoaneurysm (yellow star) (a) and its measurements on the two orthogonal axes from angiographic (b) and MDCT images (c).
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The PPF was measured with TEE and angiography that showed a diameter of 11 x 13.8 mm (Figure 3A) and 12.5 x 13.3 mm (Figure 3B), respectively.
Fluoroangiographic procedural steps. Baseline ascending aorta angiogram showing the paravalvular pseudoaneurysm (yellow star) adjacent to the bioprosthetic aortic valve (black star) and the fistula (orange arrow) causing severe regurgitation in the left ventricle (A). A preshaped extra small guidewire (Safari2) was placed across the pseudoanuerysm fistula in the left ventricle and an 8-Fr delivery sheath was advanced over it. Protection of the left main coronary artery was obtained with a coronary guidewire (small white arrows) advanced in the left coronary artery through an extra back up guiding catheter (white arrow) (B). The PLD (black arrow) was advanced into the 8-Fr delivery sheath (white arrowhead) (C). A 10 x 4-mm rectangular waist (RW) PLD (black arrow) still anchored and finally deployed in the correct position (D,E). Postprocedure angiography showing mild to moderate regurgitant jet and no impingement on the left main coronary artery (F).
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The left main coronary artery was protected with a 0.014" guidewire advanced through a 3.5 extra back up guiding catheter (Figures 4A-C). Based on the measurements made with TEE and angiography, a bigger PDL (10 x 4 mm), different both in shape (rectangular) and in type of connection (waist), with a 19-mm distal LV disc and 17-mm proximal aortic disc was advanced into the LV (Figure 4D; Supplementary Figure 2) and deployed under continuous fluoroscopic, angiographic and 2D/3D TEE guidance. A pull-and-push maneuver was performed to check PLD stability and the device was successfully deployed (Figure 4E). Final TEE and angiographic assessment confirmed the PLD stable position with moderate residual leak (Figure 4F; Supplementary Videos 2-4).