An 83-year-old male with status 5 years post pacemaker implantation due to atrial fibrillation and postoperative complete heart block following minimally invasive mitral valve replacement and tricuspid valve repair, presented at our hospital with dyspnea on exertion. He was consulted by a CVT surgeon for evaluation and treatment of recurrent postoperative severe mitral regurgitation. His physical examination revealed normotension with a pansystolic murmur at the apical area. 

The echocardiogram showed well-seated MV bioprosthesis. There was complex paravalvular regurgitation (PVL) beneath the MV at medial side of left ventricle (LV). The flow directed toward the aneurysmal sac and continued to left atrium (LA). Another smaller PVL with aneurysm was found at lateral side of LV between the LA and LV. CTA of heart revealed multifocal aneurysm from LV. A large aneurysm arose from the medial wall with a wide neck and two small aneurysms situated at posterior aspect of LV.
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Combined right and left heart catheterization was performed, showing multiple submitral outpouching lesions with some extravasation of contrast into LA. The left ventricle end diastolic pressure was 7 mmHg. The mean pulmonary arterial pressure was 13 mmHg with no step-up in oxygen saturation. The coronary angiogram was normal.
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Given his age, frailty and previous thoracic surgery, the patient was deemed to be at high risk for surgical closure. Therefore, a decision to perform percutaneous pseudoaneurysm closure was made.                              A 7Fr guiding AL1 was crossed into LV via the right femoral artery and a Terumo guidewire was able to cross into the aneurysm at the medial side of LV. We then forwarded the AL1 guiding and the Amplatzer Vascular Plug II (9/12 mm) was successfully deployed in the aneurysm. The left ventriculogram (LV gram) and transesophageal echocardiogram (TEE) were performed afterward, showing a good position of the device with a reduction of the inflow of aneurysm from LV. However, some residual flow from the aneurysm into LA was observed. So, we decided to close the fistula at the LA side. A 6Fr guiding MP1 was inserted via the right femoral vein into Agilis catheter through the interatrial septum, then placed at LA. Under TEE guidance, the V018 guidewire was successfully crossed the fistula into the aneurysm. Amplatzer Duct Occluder II (6/4 mm) was deployed under fluoroscopy and TEE guidance. The LV gram and TEE demonstrated good position of the devices without any residual flow into the aneurysm. Regarding the small pseudoaneurysm at the lateral size of LV, we planned to evaluate TEE and computer tomographic angiography of the heart 3-6 months later to reconsider the role of closure. At 1-month post-procedure, the patient reported a significant increase in exercise capacity.
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Percutaneous left ventricular pseudoaneurysm closure might be a challenging and feasible therapeutic option for high-risk surgical candidates. There is no standardized approach for left ventricular pseudoaneurysm closure. The use of multimodality imaging and proper pre-procedural planning are the key to success.