Overview of Transcatheter Management of Left Ventricular Pseudoaneurysms
Left ventricular pseudoaneurysms (LVP) are an extremely rare but serious condition that can occur following a heart attack, heart surgery, a traumatic injury, or an infection. A LVP happens when the wall of the heart’s left ventricle (the chamber that pumps oxygen-rich blood to the rest of the body) ruptures, but the break in the wall is held together by scar tissue or the sac around the heart. Symptoms of LVP can include heart failure and irregular heart rhythms, and it can sometimes lead to a fatal condition called tamponade, which is where fluid builds up around the heart and affects its ability to pump blood. Statistically speaking, LVP is an uncommon condition found in less than 1% of people.
The most common causes of LVP are heart attacks and heart surgery, which account for 55% and 33% of cases respectively. Among heart surgeries, a procedure called a mitral valve replacement is especially associated with a higher rate of LVP. Traditionally, urgent surgery has been the preferred way to handle a LVP. However, this surgery has notable risks, with death rates ranging from 20-36%. Although some recent studies show improvement in survival rates down to 10%, when surgery can’t be considered due to high risks and the patient is managed through medication, the mortality rate is almost as high as 50%.
In recent decades though, medical advancements have made a less invasive procedure called a ‘percutaneous closure’ a more viable option for treating LVP, especially in patients who would be at high risk with surgery. ‘Percutaneous’ simply means “through the skin”, and this procedure involves inserting instruments through the skin to reach and treat the heart condition. The first time this method was used to treat LVP was in 2004, and since then, its usage has grown, especially after the successful performance in 2016, following a very specific heart valve replacement procedure.
While there are no large-scale studies on this treatment for LVP just yet, various successful cases have been reported, indicating potential for growing use in the future. There’s also evidence of a hybrid approach, using the less invasive percutaneous method to initially stabilize the patient, and then following up with the traditional surgical method for a more permanent solution. This article will discuss the specifics of LVP, the causes, when percutaneous closure is appropriate, when it’s not, the technique for percutaneous closure, potential complications, and why the development of this procedure is significant.
Anatomy and Physiology of Transcatheter Management of Left Ventricular Pseudoaneurysms
The left side of your heart has a wall made up of a thick muscle. This muscle forms the thickest part of your heart. That’s why it’s more likely to develop a type of condition known as a pseudoaneurysm. A pseudoaneurysm, or a ‘false’ aneurysm, comes to be when the wall of this part of the heart gets injured, and the blood that leaks from this injury collects in the tissue around it. This is different from a true aneurysm, which happens when the walls of the heart itself bulge from fluid collecting inside them.
In simple terms, a left ventricular pseudoaneurysm is when the wall of the left side of your heart ruptures or breaks, and this rupture is contained only by the covering of the heart or scar tissue. This condition is serious and needs immediate treatment, either through surgery or a less invasive procedure called percutaneous transcatheter closure.
Research has shown that the place where a pseudoaneurysm develops is generally related to what caused it. For instance, if it’s caused by a heart attack, 82% of the time the pseudoaneurysm will be found in the bottom or back wall of the left side of the heart. In cases of congenital heart surgery, pseudoaneurysms are found in the area leading blood out of the right side of the heart 87% of the time. After a mitral valve replacement, all pseudoaneurysms are located in the area just below this valve. And after aortic valve replacement, all pseudoaneurysms are located in the region just below the aorta, the main artery of the heart.
Why do People Need Transcatheter Management of Left Ventricular Pseudoaneurysms
The best way to treat Left Ventricular Pseudoaneurysm (LVP) – a weakening in the heart’s muscle wall – is usually through an emergency surgery. However, for people who can’t undergo surgery, there’s an alternative procedure known as percutaneous transcatheter LV closure. This procedure is recommended for people who have an LVP and can’t have surgery.
When a Person Should Avoid Transcatheter Management of Left Ventricular Pseudoaneurysms
There are certain situations when a person can’t have a specific heart procedure called a percutaneous transcatheter closure. This procedure uses a catheter (a thin, flexible tube) to fix a problem in the heart. But it may not be possible to perform this procedure if:
A person has a blood clot in the left atrium of their heart. The left atrium is one of the four chambers in the heart.
A person has a condition called active endocarditis. This is an infection of the heart’s inner lining and valves.
The structure and shape of a person’s heart is such that it wouldn’t be safe or practical to perform the procedure with a catheter.
Who is needed to perform Transcatheter Management of Left Ventricular Pseudoaneurysms?
A specially trained heart doctor known as an interventional cardiologist or structuralist, who knows how to perform a procedure called a percutaneous transcatheter LV closure, is necessary for the successful and safe completion of the procedure. This method is so new that we don’t have results on how well it works yet. The doctor’s expertise and the number of times they have done the procedure are important, but because this condition is so rare, even big hospitals where specialists are referred don’t have a lot of experience with the process. The medical team during the procedure may include a heart nurse, a technician from the lab where the procedure is done, and a surgeon who specializes in heart and lung surgery.
Preparing for Transcatheter Management of Left Ventricular Pseudoaneurysms
A procedure called percutaneous transcatheter left ventricular closure is typically done urgently. However, before the actual procedure, patients need to prepare themselves. They usually need to go without food or drink for about 6 to 8 hours before the procedure. Also, if the patient is taking any blood-thinning drugs like warfarin, they should temporarily stop using it to ensure their blood can clot normally, an important factor for safe surgery, monitored using a test called INR (International Normalized Ratio). It’s ideal to get an INR of 1.7 or less before or on the day of the procedure.
In addition, doctors usually run tests to evaluate the pressure levels in the heart and lungs before the procedure. A test called a left ventriculogram is also done to look into the function and structure of the left lower part of the heart (left ventricle). Anesthesiologists, who are doctors specialized in pain management, will also evaluate the patient to plan for putting the patient to sleep (intubation) and waking them up after the procedure (extubation).
Medical imaging plays a key role in preparing for these procedures. For example, a case where a child had a balloon-like blow out on the wall of the left chamber of his heart (left ventricular pseudoaneurysm) showed the importance of detailed heart imaging. Tests like a transoesophageal echocardiogram (TOE), CT Angiogram, or cardiac MRI can provide valuable details about the shape and connections of such bulbous heart defects. These detailed images help doctors to plan a strategic approach to managing these unusual heart issues.
How is Transcatheter Management of Left Ventricular Pseudoaneurysms performed
This procedure, done under careful monitoring and anesthesia, starts by accessing the heart through a main blood vessel in your thigh. The doctor uses a special approach to reach the left upper chamber of your heart. To guide the procedure, the doctor uses a specific kind of guide catheter, which is like a long, thin tube, to locate the false aneurysm – a bulging weak spot in the heart wall. Then, a type of thin wire is inserted into the aneurysm. A small, flexible tube is slipped over the wire and into the aneurysm, and the wire is then removed.
Next, the doctor places a number of small devices called embolization coils into the aneurysm. These help to fill the space and prevent blood from flowing into it. To seal the neck of the aneurysm, the doctor uses a specific kind of plug. After the procedure, there should be no blood flow between the left lower chamber of your heart and the aneurysm.
Once the procedure is complete, you will need to stay in the hospital for 1 to 2 days for observation and to check for potential complications. It is recommended that heart scans (echocardiograms) are done regularly after surgery to make sure everything is functioning properly.
Possible Complications of Transcatheter Management of Left Ventricular Pseudoaneurysms
If a doctor fixes a bulge in the heart wall (left ventricular pseudoaneurysm) by inserting a closure device through the skin (a procedure called percutaneous transcatheter closure), there are potential complications. These can include bleeding, a swelling of clotted blood (hematoma), infection, the closure device moving to another part of the body (embolism), heart rhythm problems (arrhythmia), reliance on a pacemaker, stroke, or in some cases, death. This way of treating the problem is pretty new and isn’t done very often, because it’s rare for people to have a pseudoaneurysm. So, researchers are still trying to learn about the long-term effects or complications of this procedure.
What Else Should I Know About Transcatheter Management of Left Ventricular Pseudoaneurysms?
The development of the Percutaneous Tracheostomy Consultation (PTC) can offer potentially life-saving treatment to patients who previously were thought to be unable to undergo surgical treatment. Before this, these patients would either not be considered for surgery or would have to go through invasive procedures like sternotomy (surgery where the chest is cut open) and cardiopulmonary bypass (a technique that temporarily takes over the function of the heart and lungs during surgery), both of which come with their own risks and side effects.
