Ann Thorac Surg 2001;72:2136-2137
© 2001 The Society of Thoracic Surgeons
Case report
Acute type A aortic dissection associated with an aortic annular abscess
Yuriko Niitsuma, MD*a,
Yoshiharu Takahara, MDa,
Yoshio Sudo, MDa,
Hideyuki Nakano, MDa
a Division of Cardiovascular Surgery, Funabashi Municipal Medical Center, Funabashi, Chiba, Japan
Accepted for publication March 14, 2001.
* Address reprint requests to Dr Niitsuma, Division of Cardovascular Surgery, Funabashi Municipal Medical Center, 1-21-1 Kanasugi, Funabashi, Chiba, Japan 273-8588
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Abstract
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We describe a 66-year-old woman who underwent open heart surgery because of congestive heart failure. During operation, we found a Stanford type A dissection and an aortic ring abscess, which had burst into the aortic lumen. No other entries were found. Pathological examination showed excessive neutrophil infiltration in the aortic root. We strongly suspect that the abscess produced the intimal tear to cause the aortic dissection.
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Introduction
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Acute aortic dissection associated with infectious endocarditis is uncommon. In particular, acute aortic dissection with an aortic ring abscess as an entry is extremely rare. We describe such a case with a successful outcome.
A 66-year-old woman presented with shortness of breath and a 2-week history of fever. On admission, the blood pressure was 133/44 mm Hg. A chest roentgenogram disclosed enlargement of the heart. An electrocardiogram showed sinus rhythm. Transthoracic echocardiography revealed aortic stenosis with severe left ventricular hypertrophy. Hematological analysis revealed a white blood cell count of 13,700/mm and a hematocrit of 30.4%. The C-reactive protein level was elevated (9.8 mg/dL). The next morning, the hemodynamics had deteriorated, and intraaortic balloon pumping was performed. Emergency surgery was required for aortic valve replacement.
Median sternotomy was performed. On opening the pericardium, bloody pericardial effusion mixed with fibrin was noted. The ascending aorta was dilated. Intraoperative transesophageal echocardiography showed an aortic dissection (Stanford Type A) extending to the descending aorta. Cardiopulmonary bypass was started through left femoral arterial and the right atrial cannulations. The body temperature was lowered to 25°C. Selective cerebral perfusion was done during the cooling-down period. The ascending aorta was cross-clamped, and an incision was made in the aortic root. Crystalloid cardioplegia solution was administered directly into the coronary ostia. The patient had a bicuspid aortic valve with vegetations on the left coronary and noncoronary cusps. Active infectious endocarditis was strongly suspected. There was an annular abscess of the base of the right coronary cusp. The dissection proceeded from the aortic root to the descending aorta and continued along the circumference of the ascending aorta. In the aortic arch and descending aorta, the dissection ran along only the posterior wall. The false lumen had been closed with a fresh thrombus. An intimal tear was found on the annular abscess of the right coronary cusp. There was no other entry in the ascending aorta or aortic arch. The aortic valve was resected, and debridement of the aortic annulus was performed. A modified Bentall procedure was done according to the Piehler technique, and hemiarch replacement was performed. A composite graft made of a 22-mm polyester vascular prosthesis (Intergard Woven; Intervascular, La Ciotat, France) and a 21-mm Edwards-TEKNA mechanical valve (Baxter Health Care Corp, Edwards Division, Santa Ana, CA) was used to reconstruct the aortic root. The proximal end of the graft was sutured to the intact left ventricular muscle and buttressed with a strip of Teflon felt. The right and left coronary ostia were reconstructed by the Piehler technique. The ascending aorta and the proximal aortic arch were resected during selective cerebral perfusion and circulatory arrest. The dissected posterior wall of the arch was glued together with gelatin-resorcin-formol and buttressed inside and outside with two Teflon felt strips. Distal anastomosis was done according to the open distal method.
Pathological examination of the tissue specimens confirmed the diagnosis of active aortic valvular endocarditis and acute aortic dissection. The false lumen was located in the media. However, no cystic medical necrosis or fragmentation of the elastic laminae were found in the media. Atherosclerotic changes of the intima were minimal. Neutrophils were recognized in all layers of the aortic wall, and the extent of neutrophil infiltration was greater than in usual acute aortic dissections, especially around the false lumen and the aortic root (Fig 1).
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Fig 1. Part of the cross section of the ascending aorta near the aortic ring. The lumen is shown on the left, and the false lumen filled with blood is shown on the right. The inset on the left is a high-power view of point a. Atherosclerotic changes in the intima are minimal. The dark dots are neutrophils. Moderate infiltration of neutrophils can be seen in the intimal side of the aortic wall. The inset on the right is the high-power view of point b. The dark dots are neutrophils. The extent of neutrophilic infiltration around the false lumen is greater than that with usual acute aortic dissections. (Hematoxylin and eosin; original magnification, x20; right inset, x200; left inset, x200.)
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The patient tolerated the procedure well. Although a blood culture before operation was negative, the patient received antibiotics. She had a reversible ischemic neurological deficit and pneumonia, probably caused by aspiration, but subsequently recovered. Three months after the operation, the patient had no clinical or laboratory evidence of infection and was discharged. Currently, 5 months after the operation, she is doing well.
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Comment
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Valve ring abscesses occur in approximately 30% of patients with native valve infectious endocarditis. Many cases are not diagnosed clinically, but are found at surgery or autopsy [1]. Valve ring abscesses involve the aortic anulus much more often (95%) than the mitral valve [1]. In our case, infective endocarditis initially involved the congenital bicuspid aortic valve and then invaded the valve annulus, forming an annular abscess. We suspect that the abscess burst into the aortic intima [2], creating the intimal tear of the acute aortic dissection. Pathological findings suggested that inflammatory changes of the aortic wall weakened the ascending aorta and were related to pathogenesis of the dissection. To our knowledge, reports describing similar cases are rare [3].
Several reports have proposed that a congenital bicuspid aortic valve increases the risk of type I and II aortic dissection [4, 5]. Aortic dissection may be precipitated by weakness of the aorta due to cystic medial necrosis as well as by poststenotic hemodynamic changes [4]. Our case, however, had no cystic medial necrosis or fragmentation of the elastic laminae caused by poststenotic dilation of the aortic wall [5].
The presence of a valve ring abscess is a very poor prognostic factor, carrying a high surgical mortality rate and a poor long-term survival rate [2]. An association with acute aortic dissection would most likely contribute to increased mortality. Despite the high risk, surgical treatment produced a successful outcome in the present case.
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References
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Arnett E.N., Roberts W.C. Valve ring abscess in active infective endocarditis. Frequency, location and clues to clinical diagnosis from the study of 95 necropsy patients. Circulation 1976;54:140-145.[Abstract/Free Full Text]
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Akins E.W., Slone R.M., Wiechmann B.N., et al. Perivalvular pseudoaneurysm complicating bacterial endocarditis: MR detection in five cases. Am J Radiol 1991;156:1155-1158.[Abstract/Free Full Text]
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Abad C. Acute infectious mitroaortic endocarditis in association with acute aortic dissection. Surgical management of an unusual combination of diseases. Cardiovasc Surg 1995;3:605-606.[Medline]
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Edwards W.D., Leaf D.S., Edwards J.E. Dissecting aortic aneurysm with congenital bicuspid aortic valve. Circulation 1978;57:1022-1025.[Abstract/Free Full Text]
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Larson E.W., Edwards W.D. Risk factors for aortic dissection: a necropsy study of 161 cases. Am J Cardiol 1984;53:849-855.[Medline]
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