Percutaneous Closure of Left Ventricular Pseudoaneurysm after Direct Surgical Mitral Valve Implantation of Balloon-Expandable Transcatheter Prosthesis in Severe Mitral Annular Calcification

A 76-year-old female patient who had undergone quadruple coronary bypass surgery and aortic valve replacement 10 years earlier was referred to our clinic for severe symptomatic mitral valve stenosis secondary to extensive mitral annular calcification (MAC). Due to the high surgical risk, the excessive MAC and no possibility of an interventional approach for anatomical reasons the Heart Team opted for a hybrid approach (sternotomy with surgical transatrial mitral Valve-In-MAC procedure using a balloon-expandable Edwards SAPIEN-3 29 mm prosthesis). The intervention was successful and the patient was discharged 13 days after surgery. Despite an uneventful recovery, a transthoracic echocardiography 30 days later (Panel A) showed a left ventricular (LV) discontinuity with a paraventricular cavity suggestive of a pseudoaneurysm (astir). Computed tomography (Panel B) and angiography (Panel C) confirmed the diagnosis of a ‘bilobular’ covered perforation connecting with the LV through a narrow neck (white arrow)....