PMC3575297_01
A) A computed tomography scan showing the left ventricular apical diverticulum: note the absence of thrombi. B) Intraoperative view of the cardiac apex: macroscopically, there is no evidence of a diverticulum, whereas the palpation reveals a soft portion. C) Careful preparation of a double pledgeted 3-0 Prolene purse-string suture around the diverticulum.
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F1
Diameters were 13 mm and 16 mm (Figure 1A). From a surgical point of view, the apical approach was uneventful: macroscopically (Figure 1B), we did not observed any external sign of the presence of the diverticulum, whereas the apical palpation revealed a thinner wall in a 2 cm2 wide region. Then, the delivery system (Ascendra  2) was introduced, uneventfully, in the left ventricle through the diverticulum (Figures 1C and 2A).
A) Intraoperative view showing the introduction of the delivery system (Ascendra  2) in the apex. B) Fluoroscopic view of the stent-valve deployment under rapid pacing. C) Postoperative computed tomography scan showing the good result with partial exclusion of the diverticulum.
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F2
Then, the delivery system (Ascendra  2) was introduced, uneventfully, in the left ventricle through the diverticulum (Figures 1C and 2A). Following the standard technique a 23 mm Sapien  XT stent-valve (Edwards Lifesciences Inc., Irvine, CA) was successfully implanted with final trans-valvular mean and peak gradients of 10/4 mmHg (Figure 2B). A postoperative scan confirmed the stent-valve placement with absence of residual diverticulum in the apex (Figure 2C).