Ann Thorac Surg 1996;62:1198-1199
© 1996 The Society of Thoracic Surgeons
Case Report
LVOT Pseudoaneurysm: A Late Complication of Extended Aortic Root Replacement
James Jaggers, MD,
David A. Fullerton, MD,
David N. Campbell, MD,
David R. Clarke, MD
Division of Cardiothoracic Surgery, The Childrens Hospital, Denver, Colorado
Accepted for publication April 13, 1996.
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Abstract
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The aortic allograft has become a valuable tool for repair of complex left ventricular outflow tract defects. These operations can be performed with low morbidity and mortality; however, complications do occur. In this report, we describe a pseudoaneurysm of the left ventricular outflow tract–homograft anastomosis that presented 3 years after extended aortic root replacement.
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Introduction
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Aortic root replacement and extended aortic root replacement have become well-accepted techniques for use in repair of complex left ventricular outflow tract obstruction in pediatric patients. Large series demonstrate the excellent long-term results of root replacement, with less than 3% operative mortality; 80% freedom from reoperation, structural deterioration, and death at 15 years; and 62% 15-year survival [1–3]. However, acute complications have been reported and are usually associated with technical problems or infection. These include dehiscence, bleeding, fistula formation, and acute pseudoaneurysm. In this report, we present a pseudoaneurysm of the left ventricular outflow tract (LVOT)–homograft anastomosis presenting 3 years after extended aortic root replacement for complex LVOT obstruction.
The patient is a 12-year-old girl with complaints of left-sided chest pain that was frequently associated with exertion but occasionally occurred at rest. She had a history of coarctation of the aorta with a large perimembranous ventricular septal defect. The coarctation was repaired with resection and end-to-end anastomosis, and a pulmonary artery band was placed when she was an infant. At 6 months of age, the ventricular septal defect was repaired and the pulmonary artery debanded. At 6 years of age significant subaortic stenosis developed and she underwent resection of the subaortic membrane. At age 10 years she returned with tunnel subaortic stenosis and mild aortic valvular insufficiency. She then underwent extended aortic root replacement by the technique previously described, using a 22-mm cryopreserved aortic homograft [2]. The size of the homograft was chosen on the basis of the patient's weight (28 kg) and according to the measurement of the new outflow tract after relief of the subaortic stenosis [2]. This procedure was uncomplicated, and at 6 weeks postoperatively she was well with good left ventricular function and no structural abnormality by echocardiogram.
Three years later, she presented with complaints of chest pain. This chest pain was not associated with electrocardiographic changes or biochemical evidence of ischemia. Echocardiography at this time revealed a probable pseudoaneurysm bulging into the right atrium with swirling blood flow but no fistula. Cardiac cineangiography showed no abnormality of the coronary arteries and no allograft valve malfunction. However, a large pseudoaneurysm of the homograft–LVOT anastomosis extended to and bulged into the right atrium (Fig 1
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Fig 1. . Thirty-degree right anterior oblique view of cineangiogram showing a large pseudoaneurysm that appears to originate from the right, posterior aspect of the homograft–left ventricular anastomosis.
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At operation, the heart was cannulated, and cardiac standstill was initiated and maintained with intermittent cold blood retrograde cardioplegia. The pseudoaneurysm could be seen bulging between the right atrium and the aorta (Fig 2), making this approach to the base of the allograft difficult. The pseudoaneurysm was entered and the orifice of the pseudoaneurysm was visualized at the base of the LVOT–homograft anastomosis. To gain access to this area, we opened the right ventricular outflow tract gusset and divided the septum in the area of the previous septal patch. Two separate defects were located in the right posterior aspect and right anterior aspect of the LVOT–allograft anastomosis; each measured approximately 2 x 4 mm. These defects freely communicated with the pseudoaneurysm cavity. These were repaired using a Gore-Tex membrane patch (W. L. Gore & Assoc, Flagstaff, AZ) from the left ventricular side of the anastomosis. The interventricular septum was reclosed with a Gore-Tex patch, and the right ventricular outflow tract was closed primarily. The pseudoaneurysm cavity was then obliterated with fibrin glue and closed. The child has made an uneventful recovery and at 6-month follow-up was doing well with no evidence of recurrent pseudoaneurysm on echocardiograms.
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Comment
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Since 1956, when Murray first implanted an allograft aortic valve in a clinical setting, improvements in surgical technique and preservation methods have propelled the allograft to the forefront of use for complex LVOT reconstruction. Several large series of homograft repairs of the LVOT have been published with excellent results and longevity. The homograft has also gained popularity for use in native and prosthetic valve endocarditis [4].
Despite these good results, there is still significant potential morbidity associated with the aortic root replacement. In this report, we present a late complication of extended aortic root replacement. This proximal anastomotic pseudoaneurysm presented 3 years after an uneventful operation. Although pseudoaneurysms have been described in the early postoperative setting, they most often are associated with infection or bleeding from the coronary button or proximal anastomoses.
Aortic homografts are harvested and packaged with a variable rim of muscular tissue adjacent to the annulus. Care must be taken at the time of implantation to trim the excess periannular muscle tissue and to pass suture into the annular tissue, not into muscle tissue alone. We postulate that suture into the loose muscular tissue may result in eventual loss of integrity of the anastomosis. The majority of dehiscences of the homograft anastomosis are associated with infections; however, there was no evidence of either acute or chronic infection in this case. Another possible explanation for this complication could be long-term exposure to longitudinal tension on the suture line. It is tempting to speculate that such longitudinal tension is particularly problematic in cryopreserved tissue. Despite this unusual and unfortunate complication, which required reoperation for repair, we believe that cryopreserved aortic homografts are quite useful in the reconstruction of complex LVOT malformations.
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Footnotes
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Address reprint requests to Dr Jaggers, Duke University Medical Center, North Durham, NC 27710.
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References
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- O'Brien MF, Stafford EG, Gardner MAH, et al. Allograft aortic valve replacement: long-term follow-up. Ann Thorac Surg 1995;60:S65–70.
- Clarke DR. Extended aortic root replacement with cryopreserved allograft: do they hold up? Ann Thorac Surg 1991;52:669–75.[Abstract]
- Westaby S, Parry A, Pillai R. Aortic root replacement: modifications of technique with improvement of technology. Eur J Cardiothorac Surg 1992;6:S44–9.
- Camacho MT, Cosgrove DM III. Homografts in the treatment of prosthetic valve endocarditis. Semin Thorac Cardiovasc Surg 1995;7:32–7.[Medline]
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Abstract
Introduction
