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Ann Thorac Surg 2003;75:1331
© 2003 The Society of Thoracic Surgeons

Images in cardiothoracic surgery

Mycotic false aneurysm of the ascending aorta

Satoshi Saito, MD, PhDa, Adrian P. Banning, MRCP, FECSa, Hank Giele, FRCSa, Stephen Westaby, PhD, FECTSa*

a Department of Cardiac Surgery, Oxford Heart Centre, John Radcliffe Hospital, Oxford, United Kingdom

* Address reprint requests to Dr Westaby, Department of Cardiac Surgery, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, United Kingdom
e-mail: swestaby{at}ahf.org.uk

This 62-year-old man had previously undergone aortic valve replacement followed by mitral valve replacement with mechanical bileaflet prostheses for endocarditis. After the second operation he had a chronic sternal infection that required bone excision and pectoral muscle flap closure. He presented again 9 months later with acute central chest pain, ischemic legs, and a rapidly expanding pulsatile mass through the sternal defect. Preoperative computed tomographic scan showed a mycotic false aneurysm of the ascending aorta beneath the pectoralis muscle flap (Fig 1). A mediastinal fungal abscess beneath the muscle flaps had eroded through the anterior wall of the ascending aorta. Bilateral femoral thrombectomies produced fungus balls which grew Candida albicans.



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  		Fig 1.
 
Urgent repair of the false aneurysm was undertaken beginning with femoral arteriovenous cannulation and systemic cooling to 18°C. Under circulatory arrest, the false aneurysm was entered and an extensive fungal collection removed. There was a ragged defect (3 cm x 2 cm) in the anterior wall of the ascending aorta. This was enlarged by surgical debridement (5 cm x 3 cm) to provide a clean margin and then closed with a patch of antibiotic-sterilized aortic homograft (Fig 2A). The valve prostheses were not infected. After rewarming, he was weaned from cardiopulmonary bypass, and the mediastinal cavity was filled with packs to obtain hemostasis. Antifungal chemotherapy was initiated, and the cutaneous defect was left open.



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  		Fig 2.
 
Five days later the right latissimus dorsi muscle was removed from the chest wall with its vascular pedicle. This was used to fill the mediastinal defect and was revascularised through the right suprascapular artery and external jugular vein. The reperfused muscle was then covered with a skin graft from the right thigh (Fig 2B). Postoperatively he required a short period of hemofiltration for acute renal failure. The antifungal therapy was discontinued after 28 days. The chest wound healed without infection. A follow-up CT scan performed 6 months later showed an intact ascending aorta with a slight anterior bulge of the homograft patch at the site of repair. The latissimus dorsi muscle remained viable. There was no sign of infection (Fig 3). He is New York Heart Association functional class I.



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  		Fig 3.
 



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