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647 a coaxial microcatheter into the pseudoaneu‐ rysm, allowing deployment of 8 detachable coils, followed by a Medtronic Micro Vascular Plug de‐ vice used to seal the neck (FIGURE 1D). Postdeploy‐ ment angiography showed no flow into the pseu‐ doaneurysm. The total fluoroscopy time and to‐ tal radiation dose were 51.8 minutes and 340 mGy, respectively. Transthoracic echocardiography showed nor‐ mal left ventricular size and function and no flow into the aneurysm. A repeat chest com‐ puted tomography showed decreased fluid col‐ lections anterior to the sternum and posterior between the sternum and the descending aorta, with only residual soft tissue thickening. Percutaneous treatment, is a viable alterna‐ tive to surgery for closure of pseudoaneurysm.1,2 The size and relations of the neck of the pseudo‐ aneurysm are essential determinants for device selection. We have used the strategy of combin‐ ing packing coils within the body of the pseu‐ doaneurysm with Nitinol devices at the neck of the lesion. Fusion of f luoroscopic and echocardio‐ graphic images on the same screen facilitates appreciation of anatomical relationships, in particular the orifice of the pseudoaneurysm and close proximity of the aortic valve.3, 4 Fu‐ sion of these images with f luoroscopy made cannulation of the neck of the pseudoaneu‐ rysm straightforward and facilitated stabi‐ lization of the delivery catheter during mul‐ tiple coil and device deployment. Three months after a Ross ‐Konno procedure, an 18‐year ‐old male patient presented to his lo‐ cal hospital with wound swelling. He had been taking warfarin postoperatively as antithrom‐ botic prophylaxis. Ten milliliters of coagulat‐ ed blood was aspirated from the wound. One month later, he presented to our emergency de‐ partment with recurrent swelling. Transthorac‐ ic echocardiography showed a pulsatile struc‐ ture anterior to the aortic root and extending laterally (Supplementary material, Figure S1A). Computed tomography demonstrated a 2‐ to 3‐mm opening at the junction between the left ventricular outflow tract and the neo ‐aortic valve, leading to a false lumen (6.6 × 1.5 cm), po‐ sitioned on the left side of the aortic root (FIGURE 1A; Supplementary material, Figure S1B). This pseudoaneurysm was determined to be com‐ pressing the aortic root, right ventricular out‐ flow tract, and main pulmonary artery (Sup‐ plementary material, Figure S1C). There was also a complex subcutaneous fluid collection (3.9 × 4.2 cm) anterior to the sternum. Although no obvious connection could be identified, there was a concern for a tract be‐ tween the aneurysm and the sternal wound. Un‐ der general anesthesia, with fusion of fluoros‐ copy and 3‐dimensional transesophageal echo‐ cardiography (Supplementary material, Figure S1D) (EchoNavigator, Philips Healthcare, Best, the Netherlands), a target marker was placed to mark the entrance to the pseudoaneurysm arising from the anterolateral aspect of the left ventricular outflow tract (FIGURE 1B). This was used to position a guide catheter (FIGURE 1C) and then Correspondence to: Gareth J. Morgan, Department of Cardiology, Colorado Children’s Hospital, University of Colorado Hospital, 13 123 East 16th Avenue, Aurora, Colorado, 80 045, United States, email: gareth.morgan@ childrenscolorado.org Received: March 7, 2019. Revision accepted: April 10, 2019. Published online: May 24, 2019. Kardiol Pol. 2019; 77 (6): 647-648 doi:10.33963/KP.14841 Copyright by Polskie Towarzystwo Kardiologiczne, Warszawa 2019 C L I N I C A L V I G N E T T E

Left ventricular outflow tract pseudoaneurysm occlusion with fusion of live 3‑dimensional transesophageal echocardiography and fluoroscopy