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CASE REPORT
Year : 2013  |  Volume : 1  |  Issue : 3  |  Page : 81-82

Large aortic root pseudoaneurysm occurring late after aortic root repair and valve replacement for endocarditis


Department of Cardiology, Royal Hospital, Muscat, Oman

Date of Web Publication7-Dec-2013

Correspondence Address:
Prashanth Panduranga
Department of Cardiology, Royal Hospital, Muscat - 111
Oman
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2321-449x.122782

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  Abstract 

A 68-year-old male presented with Group B Streptococcus aortic valve (AV) endocarditis with aortic root abscess and refractory sepsis. An emergency cardiac surgery was performed with root abscess drainage, excision and debridement of necrotic tissue, reconstruction of annulus, and AV replacement. Fifteen months later he presented with a huge aortic root pseudoaneurysm (PA). This case illustrates late occurrence of aortic root PA following AV surgery for endocarditis.

Keywords: Aortic root, aortic valve, endocarditis, prosthesis, pseudoaneurysm


How to cite this article:
Panduranga P. Large aortic root pseudoaneurysm occurring late after aortic root repair and valve replacement for endocarditis. Heart India 2013;1:81-2

How to cite this URL:
Panduranga P. Large aortic root pseudoaneurysm occurring late after aortic root repair and valve replacement for endocarditis. Heart India [serial online] 2013 [cited 2020 Jul 7];1:81-2. Available from: http://www.heartindia.net/text.asp?2013/1/3/81/122782


  Case Report Top


A 68-year-old man was diagnosed to have bicuspid aortic valve (AV) with Group B streptococcus infective endocarditis 2 years earlier. He had severe aortic regurgitation with an aortic periannular root abscess and subsequently underwent aortic root and septal abscess drainage, reconstruction of left ventricular outflow tract/annulus with bovine pericardial patch, and AV replacement with size 25 Perimount prosthesis. He had two saphenous venous grafts to left anterior descending artery and obtuse marginal. Fifteen months later, he presented in refractory heart failure with no fever and negative blood cultures. A transesophageal echocardiogram showed moderate to severe mitral and aortic prosthetic valvular regurgitation [[Figure 1]a, arrowheads]. There was an aortic root pseudoaneurysm (PA) involving anterior sinus extending from AV prosthesis towards interventricular septum and right ventricle [Figure 1]b, arrowheads]. This PA was huge measuring 6.0 × 3.2 cm [[Figure 2]a and b, arrowheads]. There was no evidence of rupture or thrombus and the ejection fraction was 15%. He was in heart failure with cardiogenic shock and renal shutdown. He was offered emergency surgery, but patient and family refused. He went into pulseless electrical activity and in spite of resuscitation he expired.
Figure 1: Transesophageal echocardiogram showing moderate to severe aortic prosthetic valvular and mitral regurgitation (a, arrowheads). An aortic root pseudoaneurysm involving anterior sinus extending from aortic valve prosthesis towards interventricular septum and right ventricle (b, arrowheads). LV: Left ventricle, LA: Left atrium, RV: Right ventricle, AVP: Aortic valve prosthesis

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Figure 2: Transesophageal echocardiogram showing huge pseudoaneurysm measuring 6.0 × 3.2 cm in a patient with previous aortic root repair and aortic valve replacement for endocarditis (a and b, arrowheads). RA: Right atrium, LA: Left atrium, RV: Right ventricle, AVP: Aortic valve prosthesis

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  Discussion Top


The pathophysiolgical factors responsible for future development of aortic root PA in patients who are operated for destructive AV endocarditis are multifactorial. [1],[2],[3],[4] Causes for early occurrence of PA are refractory infection or reinfection; aortic root suture site dehiscence or inflammation can result in disruption of one of the layers of the aortic wall; in infective endocarditis due to invasive bacteria aortic root PA forms early if appropriate antibiotics are not given to prevent tissue destruction and due to extension of paravalvular aortic root abscess; and delayed diagnosis or surgery can cause more destruction of aortic periannular structures. The predominant cause for late occurrence of aortic PA post AV surgery for endocarditis is the initial extensive debridement accompanying either the aortic root repair or replacement procedures, can produce annular tissue damage that may predispose to PA in the absence of recurrence of infection. This may be the cause in this patient. In conclusion, this case illustrates a very late occurrence of aortic root PA following AV surgery for endocarditis. Literature review suggests that few preventive steps during initial management of destructive AV endocarditis can decrease the incidence of this complication, specifically early diagnosis, early institution of antibiotics, and early high quality surgery.

 
  References Top

1.Katsumata T, Moorjani N, Vaccari G, Westaby S. Mediastinal false aneurysm after thoracic aortic surgery. Ann Thorac Surg 2000;70:547-52.  Back to cited text no. 1
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2.Katayama Y, Minato N, Sakaguchi M, Nakashima A, Hisajima K. Surgical treatment of pseudoaneurysm of the sinus of Valsalva after aortic valve replacement for active infective endocarditis. Ann Thorac Cardiovasc Surg 2005;11:419-23.  Back to cited text no. 2
[PUBMED]    
3.Yuan SM, Lavee J. Pseudoaneurysm of the native sinus of Valsalva. Kardiol Pol 2009;67:291-4.  Back to cited text no. 3
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4.Kanemitsu S, Tanabe S, Ohue K, Miyagawa H, Miyake Y, Okabe M. Aortic valve destruction and pseudoaneurysm of the sinus of Valsalva associated with infective endocarditis. Ann Thorac Cardiovasc Surg 2010;16:142-4.  Back to cited text no. 4
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