Ann Thorac Surg 2008;86:e1. doi:10.1016/j.athoracsur.2008.04.062
© 2008 The Society of Thoracic Surgeons
Images in Cardiothoracic Surgery
Precocious Giant Pseudoaneurysm of an "Innocent" Ascending Aorta After Bicuspid Aortic Valve Replacement Redo
Francesco Santini, MDa,*,
Mariassunta Telesca, MDa,
Paolo Bertolini, MDa,
Anna Tomezzoli, MDb,
Nicola Schiavo, MDb,
Giuseppe Faggian, MDa,
Alessandro Mazzucco, MDa
a Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy
b Department of Pathology, University of Verona Medical School, Verona, Italy
* Address correspondence to Dr Santini, Division of Cardiac Surgery, University of Verona, Piazzale Stefani 1, Verona, 37126, Italy (Email: fsant{at}yahoo.com).
Pseudoaneurysm of the thoracic aorta results from transmural disruption of the aortic wall, with the leak contained by surrounding structures. Previous cardiac surgery is the most frequent cause. Mechanisms include infection, poor anastomotic technique, and intrinsic aortic disease.
A 52-year-old man underwent elective replacement of a dysfunctional aortic bioprosthesis implanted 7 years before for bicuspid aortic valve regurgitation. At re-do, the ascending aorta, deemed not significantly dilated (42 mm Ø) and with preserved mechanical properties, was not replaced. The patient was readmitted 10 days after discharge with chest pain. A contrast-enhanced computed tomographic chest scan revealed a huge pseudoaneurysm of the ascending aorta (10.6 x 9.5 x 11.9 cm; Fig 1A and 1B, asterisk) fed through a leak in the anterior aortic wall (Fig 1A; sagittal plane, arrow) and closely related to the sternum (Fig 1B; axial plane).
Emergency extracorporeal circulation was established by femoro-femoral cannulation and the sternum was re-entered under moderate hypothermia (24°C). Using direct antegrade brain perfusion, the pseudoaneurysm was entered and its neck was identified at the previous aortotomy suture line. The friable ascending aorta and proximal aortic arch were replaced with a 26 Vascutek prosthesis (Vascutek Terumo, Renfrewshire, Scotland). An aortic specimen showed cystic medial changes of the elastic fibers (Fig 2; hematoxylin and eosin, x10) with necrotic changes and granulocytic infiltrate (Fig 2; inset, arrow, x20). The cultures were negative. Patient recovery was uneventful.
In this underestimated case of bicuspid aortic valve, a structurally abnormal ascending aorta was left unchanged in view of a gross intraoperative evaluation and application of accredited criteria for replacement based on size match.
The risk of rupture of a pseudoaneurysm, especially when large, should always be taken into consideration as an indication for emergency surgery. Keystones of surgical treatment remain the prevention of cardiac injury during chest opening and brain protection. Beside prevention always considering the predisposing factors, accurate planning of surgical strategies based on careful assessment of the imaging tests seems to be mandatory.
