Percutaneous Closure of a Left Ventricular Outflow Tract Pseudoaneurysm Causing Extrinsic Left Coronary Artery Compression by Transseptal Approach

A 44-year-old man underwent aortic valve replacement with a porcine bioprosthesis 21 years ago for infective endocarditis complicated by a cerebral mycotic aneurysm and intracranial bleeding. Nine years ago, he had a second aortic valve replacement with a mechanical bileaflet tilting-disk prosthesis because of porcine prosthesis degeneration. No pseudoaneurysm was noted on the operative report. Six months ago, he developed angina and had a positive stress test for ischemia. Angiography showed severe left main coronary artery (LM) stenosis, which was treated with intravascular ultrasound–guided percutaneous coronary intervention with a zotarolimus-eluting stent. Two months ago, he again developed angina. Follow-up angiography and intravascular ultrasound revealed severe in-stent restenosis in the proximal third of the LM and systolic narrowing of the distal third, suggestive of extrinsic compression (Figure 1 and online-only Data Supplement Movie 1). In-stent restenosis was treated at that time with a sirolimus-eluting stent. A transesophageal echocardiogram revealed a large pseudoaneurysm lateral to the aortic root; color …