Huan-Chiu Lin

Background: Ascending aortic pseudoaneurysm due to coronary button dehiscence is a rare, yet life-threatening complication of reconstructive cardiac surgery. Because of its rare entity, large data are lacking, and therefore, treatment guidelines are missing. Case summary: We describe a case of a 53-year-old male with a past medical history of ascending aortic aneurysm and severe aortic regurgitation who underwent Bentall procedure with 26 mm conduit and mechanical aortic valve 1 year before. Follow-up chest computed tomography (CT) revealed coronary button dehiscence with a giant aortic root pseudoaneurysm and mural thrombus inside. Given the risk of rupture, the heart team decided to go for a percutaneous approach. Based on a pre-interventional 3D reconstructed CT scan and guided by transoesophageal echocardiography and intravascular ultrasound, the pseudoaneurysm was successfully occluded with a 6 × 4 mm Amplatzer Duct Occluder II and simultaneous left main coronary artery (LMCA) stenting with a 4.0 × 15 mm drug-eluting stent. Post-procedural chest CT and echocardiography revealed minimal contrast leakage posterior to the aortic root and para LMCA region, confirmed thrombosis formation post occluder and stent deployment, and patent flow of LMCA. Discussion: We describe the successful 3D reconstructed CT scan and peri-procedural transoesophageal echocardiography–guided percutaneous treatment of a giant aortic root pseudoaneurysm with an occluder and a drug-eluting stent with excellent results.

Background: Transcatheter mitral valve-in-valve (TMVIV) using the Sapien 3 (Edwards Lifesciences, Irvine, CA, USA) transcatheter heart valve is associated with high technical success and sustained valve performance. However, complications may occur or be detected during or after the procedure. Case summary: We herein describe a rare case of a 59-year-old female who underwent TMVIV for a failed surgical mitral bioprosthesis. During the procedure, the device was embolized twice into the left ventricle and left atrium, respectively, resulting from the crimped transcatheter valve partially detaching from the balloon of the Certitude delivery system during passage through a tight transapical sheath. Fortunately, we were able to catch the dislodged valve and anchor it by the partially inflated device balloon, followed by successful repositioning and deployment. Discussion: In cases where the valve has already detached, as in the present case, the sheath may be advanced against the proximal end of the valve as a pusher, providing good support to push the entire system to cross the bioprosthesis. Then, the delivery catheter should be withdrawn with the counteraction of the sheath in order to correct the interrelated positions of the valve and the balloon. Finally, the valve can be positioned and deployed after the sheath is withdrawn.