Ann Thorac Surg 1997;63:1770-1771
© 1997 The Society of Thoracic Surgeons
Case Report
Marfanoid Aneurysm in Donor Aorta After Transplantation
Vivek L. Pathi, FRCS,
Thaseegaran M. Pillay, FRCS,
David J. Wheatley, MD,
Philip R. Belcher, MD,
Surendra K. Naik, PhD
Department of Cardiac Surgery, Royal Infirmary, Glasgow, Scotland
Accepted for publication January 20, 1997.
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Abstract
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A case is reported of dissecting aneurysm of the donor ascending aorta and root 4 years after orthotopic cardiac transplantation. The pathology raises the possibility of Marfan's syndrome in the donor.
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Introduction
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With the exception of mycotic lesions, aneurysmal change in the donor aorta when associated with cystic medial degeneration is a rare event after cardiac transplantation. We report a patient in whom severe dilatation of the ascending aorta developed 4 years after orthotopic cardiac transplantation.
A 59-year-old man underwent orthotopic cardiac transplantation for end-stage ischemic heart disease. The donor was a 29-year-old man, 190 cm tall but weighing only 60 kg, who had died of a subarachnoid hemorrhage. In addition to the heart, only the corneas of this patient were used, and no ocular abnormalities were noted by the surgeons. The kidney was horseshoe and not suitable.
Early graft function was excellent, but the patient suffered three episodes of severe rejection within the first 3 months, requiring three pulses of intravenous steroids and two reducing courses of oral prednisolone. As a consequence, pulmonary aspergillosis developed, which responded to intravenous liposomal amphotericin. At no stage were blood cultures positive, nor did he have evidence of mediastinal or wound-related sepsis. There was no development of hypertension over the ensuing period. His progress over the next few years was unremarkable, but he presented once more, 4 years later, suffering from breathlessness and evidence of aortic regurgitation.
Echocardiography revealed marked dilatation of his ascending aorta to a diameter of 9 cm, with severe aortic regurgitation. This was confirmed by contrast computed tomographic scan (Fig 1
). There was no evidence of systemic infection on blood cultures and no elevation of markers such as C-reactive protein level. He was taken to the operating room, and through a repeat median sternotomy, a large aneurysm involving the entire aortic root but strictly restricted to donor tissue was found (Fig 2). There was a dissection flap originating from the ascending aorta but not crossing the anastomotic suture line. The aortic valve was tricuspid in morphology but severely distorted and regurgitant.
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Fig 1. . Computed tomographic scan demonstrating huge dilatation of the aortic root. (1 = normal descending aorta; 2 = aneurysmal donor aortic root.)
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Fig 2. . Operative photograph (A) and line drawing (B) of opened aorta, revealing dissection flap (IF) and aneurysmal aortic root (Ao). The aorta returns to normal at the suture line (SL), which is clearly visible.
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Cannulation was carried out using the native aorta and right atrium. The aneurysm was opened longitudinally and an aortic root replacement carried out using a 27-mm stentless porcine prosthesis (Freestyle; Medtronic Ltd, Herts, England), with reimplantation of the coronary arteries (Fig 3). A 27-mm Gelseal tube graft (Vascutek Ltd, Renfrewshire, Scotland) was interposed between the porcine and recipient aortas.
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Fig 3. . Operative photograph after replacement of the aortic root with a stentless porcine prosthesis.
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The patient made an uneventful recovery and was discharged home on day 26. On review at 3 months, he was well, with no symptoms or echocardiographic signs of cardiac dysfunction. Histologic examination of the resected aorta revealed dissection with cystic medial degeneration. No evidence of mycotic infection, past or present, was seen on bacteriologic examination.
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Comment
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Aneurysmal change in the donor aorta after orthotopic cardiac transplantation is extremely rare in the absence of infection. This complication has, however, been reported in the native aorta after heterotopic cardiac transplantation [1]. In this instance, the entry site stemmed from a flap at the suture line, and was not primary aortic disease. Mycotic infections are by far the most common cause of this form of aortic degeneration after transplantation [2]. These can rupture and present as emergencies, but invariably tend to have evidence of active fungal infection [3]. If not causing direct damage to the aorta, these microorganisms can cause an arteritis leading to aneurysmal change in the vascular walls. The most dramatic presentation after mediastinitis in these patients is anastomotic disruption at the donor-recipient aortic suture line [4]. These are invariably fatal. It is unlikely that the primary pathology in our patient was infective, as there was no evidence of this on microscopic examination. Similarly, the intimal flap stopped short of the suture line, making this an unlikely source of the primary entry site for an iatrogenic dissection.
Our case is unusual in that the donor aorta was the site of cystic medial necrosis, leading to dissecting aneurysm. Although the habitus of the donor was clearly marfanoid, this was not considered a contraindication at the time of retrieval. In retrospect, however, the aortic histology may be considered a criterion for Marfan's syndrome, as may the habitus. The precise diagnosis would be confounded, however, by changes occurring in a transplanted organ, subjected to rejection and inflammatory infiltration. Careful follow-up will be warranted to detect any other possible cardiac sequelae if this heart is presumed to be affected by such a primary pathology. Although the use of a porcine heterograft may be considered controversial in this case, the avoidance of warfarin may be a major advantage in the setting of the polypharmacy after transplantation. The Dacron cuff on the inflow aspect of this prosthesis should resist future dilatation at this site.
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Footnotes
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Address reprint requests to Dr Naik, Department of Cardiac Surgery, Royal Infirmary, 10 Alexandra Parade, Glasgow G31 2ER, Scotland.
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References
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- Martinelli L, Rinaldi M, Pederzolli C, et al. Successful treatment of aortic dissection after heterotopic heart transplantation. Ann Thorac Surg 1995;59:990–3.[Abstract/Free Full Text]
- Follis FM, Paone RF, Wernly JA, et al. Mycotic aneurysm of the ascending aorta after coronary revascularization. Ann Thorac Surg 1994;58:236–8.[Abstract/Free Full Text]
- Byl B, Jacobs F, Antoine M, et al. Mediastinitis caused by Aspergillus fumigatus with ruptured aortic pseudoaneurysm in a heart transplant recipient. Heart Lung J Crit Care 1993;22:145–7.
- Dowling RD, Baladi N, Zenati M, et al. Disruption of the aortic anastomosis after heart-lung transplantation. Ann Thorac Surg 1990;49:118–22.[Abstract/Free Full Text]
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Abstract
Introduction
