A 27-year old intravenous drug user presented to our institution with chest pain. She had a history of bicuspid aortic valve endocarditis with aortic root abscess repaired with bioprosthetic aortic valve replacement and pericardial patch reconstruction of the left ventricular outflow tract and non-coronary sinus 6-weeks previously. Echocardiographic and cardiac CT imaging confirmed 3 foci of breakdown of the pericardial patch repair with active bleeding into a large posterior pseudoaneurysm (92mm diameter) compressing the left atrium and pulmonary artery. Following multidisciplinary discussion, the consensus was to attempt urgent percutaneous closure of the defect given prohibitive surgical risks. The procedure was performed under fluoroscopic and 3D-transoesophageal guidance. TOE demonstrated the pericardial patch breaches and active bleeding into the large pseudoaneurysm. Initial deployment of an Amplatzer Vascular Plug (AVP-2) device resulted in significant flow reduction but there remained two small peri-device leaks. During an attempt to implant an additional smaller Amplatzer device to rectify this, the initial device dislodged and embolised into the pseudoaneurysm. This was felt irretrievable and unlikely to be clinically significant given its containment. The embolised device freely floated within the pseudoaneurysm, uniquely akin to a satellite orbiting in space. The secondary device was removed and initial breach satisfactorily closed with a 15mm-sized Amplatzer atrial septal defect occluder (third device). This was confirmed to be well-seated on real-time 3D imaging with negligible residual leak on TOE. This is the first published case of percutaneous cardiac device embolization into a pseudoaneurysm cavity that we are aware of.
Handi Salim, Martin Been, David Hildick-Smith and Jamal Nasir Khan
Viren Ahluwalia, Faizel Osman, Jitendra Parmar and Jamal Nasir Khan
Despite 3D echocardiography (3DE) acquiring significantly greater data than standard 2D echocardiography (2DE), it is underutilised in assessing cardiac anatomy and physiology. A key advantage is the ability of a single 3DE acquisition to be post-processed to generate volume-rendered 3D models and an unlimited number of multiplanar reconstruction (MPR) images. We describe the case of a highly anxious patient with life-threatening complex aortic valve endocarditis and aortic root abscess, refusing transesophageal echocardiography (TOE) under general anaesthesia with tachycardia, breathlessness and acute kidney injury precluding accurate or safe gated (computed tomography) CT, who was comprehensively assessed with a rapid 3D-TOE under sedation. This led to timely surgery and an excellent outcome for the patient.
- 3DE is of greater clinical value than 2DE as it is able to post-process a single 3DE image acquisition into volume rendered 3D models, and provide an unlimited number of multiplanar reconstruction (MPR) images.
- 3DE is highly effective in difficult cases where speed is important.
- 3DE is superior in the planning of complex surgical cases.