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Ann Thorac Surg 1997;63:529-531
© 1997 The Society of Thoracic Surgeons

Case Report

Double Mycotic Aneurysms of the Ascending Aorta

Ying-Fu Chen, MD, Pao-Yen Lin, MD, Hsueh-Wei Yen, MD, Ching-Cheng Lin, MD

Division of Cardiovascular Surgery, Department of Surgery, and Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical College, Kaohsiung, Taiwan

Accepted for publication August 12, 1996.


   Abstract
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 Footnotes
 Abstract
Introduction
 Comment
 References
 
Infection in the vascular tree has been proved to be one of the greatest challenges for cardiovascular surgeons. Of these, mycotic aneurysms of the ascending aorta were considered to be almost always lethal until recently. A thorough survey of the literature indicates that only 42 cases of mycotic aneurysm of the ascending aorta have been reported. All the reported cases of mycotic aneurysm of the ascending aorta were a single lesion in the ascending aorta except a case reported in 1993. This report describes an additional case of double mycotic aneurysms of the ascending aorta caused by Pseudomonas infection.


   Introduction
Top
 Footnotes
 Abstract
 Introduction
Comment
 References
 
Infection in the vascular tree has been proved to be one of the greatest challenges for cardiovascular surgeons. Bennett and Cherry [1] stated in 1967 that patients with mycotic aortic aneurysms had an inevitably lethal course. Recently, despite technical advances and newer antibiotics, the morbidity and mortality remain high [2]. In reviewing the literature, we found only 42 cases of mycotic aneurysm of the ascending aorta. Nine cases were reported in the first half of this century and 33 cases from 1964 to 1995. Therefore, only small series or isolated cases were described in the literature. A thorough survey of the literature indicates that all reported cases of mycotic aneurysm of the ascending aorta were a single lesion in the ascending aorta except a case reported by Pasic and associates in 1993 [3]. One of their 6 reported cases was double lesions in the ascending aorta. Thus, our presented case is the second case of double mycotic aneurysms of the ascending aorta.

On January 11, 1994, a 30-year-old man underwent aortic valve replacement with a St. Jude Medical valve because of infectious endocarditis of the aortic valve caused by Pseudomonas aeruginosa. Postoperatively, he continued to receive 6 weeks of antibiotic therapy parenterally and then was maintained on an oral antibiotic regimen after dismissal from the hospital.

Half a month later, he was readmitted because of fever and general malaise. Pseudomonas aeruginosa was grown in blood cultures. The white blood cell count was 17,370/µL with a shift to left. During this hospitalization, a triple antibiotic regimen with imipenem, ceftazidime, and moxalactam parenterally was instituted for 2 months and then continuing oral antibiotic therapy. Over the subsequent several months, he had increasing disability due to congestive heart failure, bilateral pleural effusion, ascites, and hepatomegaly. Cardiac echography demonstrated severe aortic regurgitation, moderate pulmonary regurgitation, moderate tricuspid regurgitation, and impaired left ventricular function. Chest roentgenography showed a widened mediastinum. Magnetic resonance imaging (Fig 1Go) identified a lobulated pseudoaneurysm along the right lateral portion of the ascending aorta. Aortograms (Fig 2Go) confirmed two pseudoaneurysms of the ascending aorta, aortic regurgitation, and supravalvular stenosis.



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  		Fig 1. . Magnetic resonance image showing a lobulated pseudoaneurysm along the right lateral portion of the ascending aorta.

 


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  		Fig 2. . Aortograms in right anterior oblique 30-degree (A) and left anterior oblique 60-degree (B) projections showing two pseudoaneurysms of the ascending aorta, aortic regurgitation, and supravalvular stenosis.

 
On November 11, 1994, 10 months after the initial operation, surgical repair was performed using femoral cannulation. Cardiopulmonary bypass and moderate systemic hypothermia were instituted. After reopening of the sternum, a large inflammatory mass measuring 6 x 4 cm was found between the ascending aorta and right atrium. During exploration of the aorta, two defects were found in the ascending aorta. The first defect, 8 mm in diameter, was located at the midportion of the right lateral ascending aortic wall. The second one, 15 mm in diameter, was found at the lower portion of the right lateral ascending aorta near the aortic root. Subsequently, the large pseudoaneurysm was incised and a thickened, fibrotic septum with a small central opening was found, which separated the upper and lower pseudoaneurysms. Moreover, a defect 10 mm in diameter was located at the base of the lower pseudoaneurysm, which communicated to the healed aortic root abscess cavity. The aortic root abscess cavity was carefully inspected. The site of the healed aortic root abscess cavity was adjacent to the perimeter of noncoronary sinus. There was a cavity orifice 15 mm in diameter, surrounding with fibrotic tissue, connected to left ventricular cavity. This could explain why severe aortic regurgitation was identified by preoperative angiography, yet intraoperatively the mechanical aortic prosthesis was found to function well.

These two communicating mouths, connecting to the left ventricle and the lower pseudoaneurysm, respectively, of the aortic root abscess cavity were securely closed with patches of equine pericardium. The St. Jude Medical valve itself was free of vegetation and functioned well and hence was conserved. The defects in the ascending aorta were repaired with equine pericardial patches. Meanwhile, the supravalvular aortic stenosis was also augmented by equine pericardium.

The patient made an uneventful recovery. After 3 months of antibiotic treatment parenterally, he was discharged home. He continued to receive oral antibiotics after discharge, and this regimen will be followed for the rest of his life. Presently, the patient is doing well at 1 year and 4 months of follow-up.


   Comment
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 Footnotes
 Abstract
 Introduction
 Comment
References
 
A survey of the literature shows that Staphylococcus aureus was the dominant organism in patients after open heart procedures for mycotic aneurysm of the ascending aorta. On the other hand, Candida was more common in patients after heart or heart-lung transplantation [4]. However, the infective organism of our presented case was Pseudomonas aeruginosa. This highly virulent organism has rarely been reported in patients with mycotic aneurysm of the ascending aorta.

Surgical management of the mycotic aneurysm of the ascending aorta was frequently complicated by the dense adherence of the retrosternal tissues. Dissection to identify mediastinal structures can result in uncontrollable hemorrhage, even death. Thus, mycotic aneurysms of the ascending aorta were considered to be almost always lethal until recently [5]. Therefore, although it is rare, it is probably more frequent than reported in the literature due to often fatal outcome of attempts at repair [4]. The technique used in the management of this patient included cardiopulmonary bypass and moderate systemic hypothermia after femorofemoral cannulation. However, alternative techniques deserve consideration if the problems of uncontrollable hemorrhage or inability to obtain control for repair of the aortic defects are encountered because of the dense adherence of the retrosternal tissues. The alternative strategies, such as deep hypothermia and low flow, deep hypothermia and circulatory arrest, or moderate to deep hypothermia with retrograde cerebral perfusion [6], would be used to improve exposure and minimize bleeding.

The patch material for the repair of the mycotic aneurysm of the ascending aorta should be as nonreactive as possible. Pericardium or homograft tissue is preferable, as Dacron can become seeded with organisms, thereby leading to persistent or recurrent infection. Thus, a prosthetic graft as a patch or vascular conduit is the last choice [3]. We therefore repaired all the defects, including augmentation of the supravalvular aortic stenosis, with patches of equine pericardium. The supravalvular aortic stenosis was not found at the primary operation for endocarditis of the native aortic valve. The exact mechanism that induced stenosis was unknown. Presumably, it was caused by external compression of the pseudoaneurysm. In view of late infectious recurrences, the Baylor University group [2] has repeatedly recommended life-long antibiotic coverage. This approach not only may prevent serious and potentially lethal recurrences but also may cure them, especially pseudomonal infections that present as a highly virulent disease with antibiotic refractoriness. Recently, the concept of in situ reconstruction with an aortic homograft and short-term antibiotic therapy seems more acceptable than in situ reconstruction with a synthetic graft and prolonged or even lifelong antibiotic therapy. However, this promising concept in reconstructive arterial surgery needs support by larger clinical series with extended follow-up [7]. Moreover, it remains to be determined whether the concept of short-term antibiotic therapy can be similarly accepted for highly virulent pathogens such as Pseudomonas with the possibility of late recurrent infection.


   Footnotes
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 Footnotes
Abstract
 Introduction
 Comment
 References
 
Address reprint requests to Dr Chen, Division of Cardiovascular Surgery, Department of Surgery, Kaohsiung Medical College, 100 Shih-Chuan 1st Rd, Kaohsiung, Taiwan.


   References
Top
 Footnotes
 Abstract
 Introduction
 Comment
 References
 

  1. Bennett D, Cherry J. Bacterial infection of aortic aneurysms. Am J Surg 1967;113:321–6.[Medline]
  2. Chan FY, Crawford ES, Coselli JS, Safi HJ, Williams TW. In situ prosthetic graft replacement for mycotic aneurysm of the aorta. Ann Thorac Surg 1989;47:193–203.[Abstract/Free Full Text]
  3. Pasic M, Carrel T, von Segesser L, Turina M. In situ repair of mycotic aneurysm of the ascending aorta. J Thorac Cardiovasc Surg 1993;105:321–6.[Abstract]
  4. Follis FM, Paone RF, Wernly JW. Mycotic aneurysm of the ascending aorta after coronary revascularization. Ann Thorac Surg 1994;58:236–8.[Abstract/Free Full Text]
  5. Gross C, Harringer W, Mair R, Wimmer-Greinecker G, Klima U, Brucke P. Mycotic aneurysms of the thoracic aorta. Eur J Cardiothorac Surg 1994;8:135–8.[Abstract/Free Full Text]
  6. Ueda Y, Miki S, Kusuhara K, Okita Y, Tahata T, Yamanaka K. Surgical treatment of aneurysm or dissection involving the ascending aorta and aortic arch, utilizing circulatory arrest and retrograde cerebral perfusion. J Cardiovasc Surg 1990;31:553–8.[Medline]
  7. Pasic M. Mycotic aneurysm of the aorta: evolving surgical concept. Ann Thorac Surg 1996;61:1053–4.[Free Full Text]



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