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Aortic root pseudoaneurysm causing hemodynamic and electrical instability very late after aortic valve repair
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MODEL
Hellenic Society of Cardiology (2017) xx, 1e3
Available online at www.sciencedirect.com
ScienceDirect journal homepage: http://www.journals.elsevier.com/ hellenic-journal-of-cardiology/
LETTER TO THE EDITOR
Aortic root pseudoaneurysm causing hemodynamic and electrical instability very late after aortic valve repair
KEYWORDS ascending aorta pseudoaneurysm; multimodality imaging; aortic surgery; transesophageal echocardiography
Ascending aorta pseudoaneurysm is a rare complication of aortic surgery, usually ensuing early in the portoperative period. Herein we report the case of a 30-year-old man with aortic root pseudoaneurysm presenting with hemodynamic and electrical instability 15 years after operation, underscoring the role of multimodality imaging in the prompt recognition and management of this entity. A 30-year-old man presented with acute pulmonary edema. He had history of bicuspid aortic valve (AV) with AV repair 15 years before. On transthoracic echocardiography (TTE), the left ventricle was moderately dilated with reduced ejection fraction (EF). The AV was dysplastic and displayed severe mixed disease (prominently regurgitation), and the ascending aorta (AAo) was also dilated (48 mm). A cavity measuring 4 2 cm was detected between the AAo and the left atrium (Figure 1A, Video 1). On transesophageal echocardiography, the cavity appeared to originate from the non-coronary sinus of Valsalva and to communicate with the AAo (Figure 1B, Video 2), exhibiting systolic flow from the AAo into the cavity, which reversed during diastole (Video 3). Multidetector computed tomography angiography (CTA) confirmed these findings (Figure 1C). After being initially stabilized, the patient presented hemodynamic and electrical instability and was referred for emergent surgery. Intraoperatively, there was evidence of rupture of the aortic root at the site of the noncoronary sinus of Valsalva and a pseudoaneurysm Peer review under responsibility of Hellenic Society of Cardiology.
protruding above the left atrium. The pseudoaneurysm was repaired using a pericardial patch. The AV and AAo were replaced with a mechanical valve and an artificial graft, respectively. There was no evidence of active endocarditis. Postoperatively, the patient was supported by intra-aortic balloon pump for 10 days. He was discharged on the 18th day. At the time of discharge, he had severely reduced left ventricular systolic function (EFw25%) and was moderately symptomatic (New York Heart Association class II). Three months later, and while on heart failure treatment, he had improved significantly, exhibiting good systolic left ventricular functiondthe EF was now close to normal, 50%d and para-aortic cavity thrombosis. After 8 months, he was asymptomatic with normal EF and no cavity on TTE (Video 4). Magnetic resonance angiography (MRA) confirmed the remarkable decrease in the size of the para-aortic cavity (Figure 1D, Video 5). After 1.5-year, the patient remains in good clinical condition. Supplementary data related to this article can be found online at http://dx.doi.org/10.1016/j.hjc.2017.06.001. The following are the Supplementary data related to this article:
This case illustrates a rare late complication of aortic surgery, AAo pseudoaneurysm (AAP), and highlights the importance of heightened clinical suspicion and appropriate referral for multimodality cardiac imaging in patients who have undergone aortic surgery and become symptomatic. Aortic rupture and AAP formation after AV surgery is a rare but potentially lethal complication. AAP results from the disruption of the intima and the media of the aorta with the leak contained between the adventitia and the surrounding structures of the mediastinum. It is generally associated with composite grafts (valve and conduit) and develops at previous anastomotic sites in the early postoperative period. AAPs occur in only <0.5% of all aortic surgical cases (1). Patients can be asymptomatic or suffer serious complications including heart failure from compression of the right ventricular outflow tract or from
http://dx.doi.org/10.1016/j.hjc.2017.06.001 1109-9666/ª 2017 Hellenic Society of Cardiology. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Please cite this article in press as: Bonou M, et al., Aortic root pseudoaneurysm causing hemodynamic and electrical instability very late after aortic valve repair, Hellenic Society of Cardiology (2017), http://dx.doi.org/10.1016/j.hjc.2017.06.001
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MODEL
2
Letter to the Editor
Figure 1 (A) Transthoracic echocardiogram (four-chamber view) showing a cavity (asterisk) between the aortic root and the left atrium. (B) Transesophageal echocardiogram showing a cavity (asterisk) arising from the non-coronary sinus of Valsalva and communicating with the ascending aorta. (C) Preoperative computed tomography scan (oblique view) showing a cavity (asterisk) between the aortic root and the left atrium, measuring 42 mm at its largest diameter. In addition, note the calcified aortic valve (arrowhead). (D) Systolic frame from a cine image before gadolinium administration in the aortic prosthesis plane. The arrows point to the para-aortic cavity, which has reduced size and now appears full of material. LA, left atrium; LV, left ventricle; AAo, ascending aorta; RV, right ventricle; MAV, mechanical aortic valve.
aortopulmonary fistula, cerebral embolism from pseudoaneurysm thrombus, angina from coronary artery compression, pain from sternum erosion or tamponade from rupture into the pericardium, cardiopulmonary arrest, and death (2, 3). Because of the high risk of rupture, AAPs require immediate invasive therapy, usually surgery. Operative goals are removal of the impinged tissue, restoration of hemodynamic function, and correction of the mechanical defect (4). However, reoperation in these patients is highly invasive and challenging because of adhesions and is associated with considerable mortalitydup to 46%. Anteriorly located AAPs situated <2 cm from the sternum are high-risk features that may complicate chest re-entry (5). The main intraoperative concerns are bleeding avoidance during sternotomy and maintenance of proper cerebral perfusion. Alternatively, in high-risk patients, endovascular therapies using stent grafts, coil embolization, thrombin injection, or occluder devices have the advantage of being less invasive, yet limitations remain (6). Multimodality imaging after aortic surgery enables the accurate diagnosis of such severe complications and helps determine the surgical plan. In our patient, it was repeated
on a 3-month interval basis postoperatively for the first year and yearly thereafter. Although CTA and MRA are useful diagnostic modalities, nephrotoxicity, radiation exposure (with CTA), and high costs (for MRA) limit their use as lifelong surveillance tools (7). It seems prudent to attempt to reduce the number of these exams per patient, depending on preoperative indication and surgical result. Our young patient who underwent a successful operation and had near-normal findings 1.5 year after surgery was scheduled for yearly TTE with a view to repeat MRA every 2e3 years.
Conflict of interest None declared.
References 1. Di Eusanio M, Berretta P, Bissoni L, Petridis FD, Di Marco L, Di Bartolomeo R. Re-operations on the proximal thoracic aorta: results and predictors of short- and long-term mortality in a
Please cite this article in press as: Bonou M, et al., Aortic root pseudoaneurysm causing hemodynamic and electrical instability very late after aortic valve repair, Hellenic Society of Cardiology (2017), http://dx.doi.org/10.1016/j.hjc.2017.06.001
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MODEL
Letter to the Editor
2.
3.
4.
5.
6.
7.
series of 174 patients. Eur J Cardiothorac Surg. 2011;40: 1072e1076. Valero E, Santas E, Machado E, Nunez J. Pseudoaneurysm with fistulization to the lift atrium; a very late complication of previous aortic valve surgery. Int J Cardiol. 2016;212:145e147. Rallidis LS, Kelekis NL, Psaroyannakopoulos P, Antoniadis A, Anastasiou-Nana M. Multiple aortic pseudoaneurysms due to detachment of the composite graft after Bentall Operation. Hell J Cardiol. 2013;54:464e465. Perrotta S, Lentini S. Surgical management of severe damage of the aortic annulus. Hell J Cardiol. 2016. http://dx.doi.org/10. 1016/j.hjc.2016.11.012. Berretta P, Di Marco L, Pacini D, Cefarelli M, Alfonsi J, Castrovinci S, et al. Reoperations versus primary operation on the aortic root; a propensity score analysis. Eur J Cardiothorac Surg. 2017;51:322e328. Seratzis N, Melas N, Seratzis A, Lazaridis J, Kiskinis D. Minimally invasive endovascular intervention in emergent and urgent thoracic pathologies: single center experience. Hell J Cardiol. 2008;49(5):312e319. Katsargyris A, Verhoeven EL. Part two: against the motion. All TEVAR patients do not require lifelong follow-up by annual CTA/ MRA. [Con]. Eur J Vasc Endovasc Surg. 2012;44:538e541.
3 Maria Bonou, MD, PhD Eva D. Papadimitraki, MD, PhD * Department of Cardiology, Laiko General Hospital, Athens, Greece Fotios Mitropoulos, MD, PhD Andreas Karabinis, MD, PhD Onassis Cardiac Surgery Center, Athens, Greece George Anastasiadis, MD John Barbetseas, MD, PhD Department of Cardiology, Laiko General Hospital, Athens, Greece *Corresponding author. Eva D Papadimitraki, M.D., Ph.D., Department of Cardiology, Laiko General Hospital, 17 Agiou Thoma Street, 11527, Goudi, Athens, Greece. Tel.: þ30 2107456258; fax: þ30 2132061761. E-mail address: [email protected] (E.D. Papadimitraki) 26 February 2017
Please cite this article in press as: Bonou M, et al., Aortic root pseudoaneurysm causing hemodynamic and electrical instability very late after aortic valve repair, Hellenic Society of Cardiology (2017), http://dx.doi.org/10.1016/j.hjc.2017.06.001
MODEL
Hellenic Society of Cardiology (2017) xx, 1e3
Available online at www.sciencedirect.com
ScienceDirect journal homepage: http://www.journals.elsevier.com/ hellenic-journal-of-cardiology/
LETTER TO THE EDITOR
Aortic root pseudoaneurysm causing hemodynamic and electrical instability very late after aortic valve repair
KEYWORDS ascending aorta pseudoaneurysm; multimodality imaging; aortic surgery; transesophageal echocardiography
Ascending aorta pseudoaneurysm is a rare complication of aortic surgery, usually ensuing early in the portoperative period. Herein we report the case of a 30-year-old man with aortic root pseudoaneurysm presenting with hemodynamic and electrical instability 15 years after operation, underscoring the role of multimodality imaging in the prompt recognition and management of this entity. A 30-year-old man presented with acute pulmonary edema. He had history of bicuspid aortic valve (AV) with AV repair 15 years before. On transthoracic echocardiography (TTE), the left ventricle was moderately dilated with reduced ejection fraction (EF). The AV was dysplastic and displayed severe mixed disease (prominently regurgitation), and the ascending aorta (AAo) was also dilated (48 mm). A cavity measuring 4 2 cm was detected between the AAo and the left atrium (Figure 1A, Video 1). On transesophageal echocardiography, the cavity appeared to originate from the non-coronary sinus of Valsalva and to communicate with the AAo (Figure 1B, Video 2), exhibiting systolic flow from the AAo into the cavity, which reversed during diastole (Video 3). Multidetector computed tomography angiography (CTA) confirmed these findings (Figure 1C). After being initially stabilized, the patient presented hemodynamic and electrical instability and was referred for emergent surgery. Intraoperatively, there was evidence of rupture of the aortic root at the site of the noncoronary sinus of Valsalva and a pseudoaneurysm Peer review under responsibility of Hellenic Society of Cardiology.
protruding above the left atrium. The pseudoaneurysm was repaired using a pericardial patch. The AV and AAo were replaced with a mechanical valve and an artificial graft, respectively. There was no evidence of active endocarditis. Postoperatively, the patient was supported by intra-aortic balloon pump for 10 days. He was discharged on the 18th day. At the time of discharge, he had severely reduced left ventricular systolic function (EFw25%) and was moderately symptomatic (New York Heart Association class II). Three months later, and while on heart failure treatment, he had improved significantly, exhibiting good systolic left ventricular functiondthe EF was now close to normal, 50%d and para-aortic cavity thrombosis. After 8 months, he was asymptomatic with normal EF and no cavity on TTE (Video 4). Magnetic resonance angiography (MRA) confirmed the remarkable decrease in the size of the para-aortic cavity (Figure 1D, Video 5). After 1.5-year, the patient remains in good clinical condition. Supplementary data related to this article can be found online at http://dx.doi.org/10.1016/j.hjc.2017.06.001. The following are the Supplementary data related to this article:
This case illustrates a rare late complication of aortic surgery, AAo pseudoaneurysm (AAP), and highlights the importance of heightened clinical suspicion and appropriate referral for multimodality cardiac imaging in patients who have undergone aortic surgery and become symptomatic. Aortic rupture and AAP formation after AV surgery is a rare but potentially lethal complication. AAP results from the disruption of the intima and the media of the aorta with the leak contained between the adventitia and the surrounding structures of the mediastinum. It is generally associated with composite grafts (valve and conduit) and develops at previous anastomotic sites in the early postoperative period. AAPs occur in only <0.5% of all aortic surgical cases (1). Patients can be asymptomatic or suffer serious complications including heart failure from compression of the right ventricular outflow tract or from
http://dx.doi.org/10.1016/j.hjc.2017.06.001 1109-9666/ª 2017 Hellenic Society of Cardiology. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Please cite this article in press as: Bonou M, et al., Aortic root pseudoaneurysm causing hemodynamic and electrical instability very late after aortic valve repair, Hellenic Society of Cardiology (2017), http://dx.doi.org/10.1016/j.hjc.2017.06.001
+
MODEL
2
Letter to the Editor
Figure 1 (A) Transthoracic echocardiogram (four-chamber view) showing a cavity (asterisk) between the aortic root and the left atrium. (B) Transesophageal echocardiogram showing a cavity (asterisk) arising from the non-coronary sinus of Valsalva and communicating with the ascending aorta. (C) Preoperative computed tomography scan (oblique view) showing a cavity (asterisk) between the aortic root and the left atrium, measuring 42 mm at its largest diameter. In addition, note the calcified aortic valve (arrowhead). (D) Systolic frame from a cine image before gadolinium administration in the aortic prosthesis plane. The arrows point to the para-aortic cavity, which has reduced size and now appears full of material. LA, left atrium; LV, left ventricle; AAo, ascending aorta; RV, right ventricle; MAV, mechanical aortic valve.
aortopulmonary fistula, cerebral embolism from pseudoaneurysm thrombus, angina from coronary artery compression, pain from sternum erosion or tamponade from rupture into the pericardium, cardiopulmonary arrest, and death (2, 3). Because of the high risk of rupture, AAPs require immediate invasive therapy, usually surgery. Operative goals are removal of the impinged tissue, restoration of hemodynamic function, and correction of the mechanical defect (4). However, reoperation in these patients is highly invasive and challenging because of adhesions and is associated with considerable mortalitydup to 46%. Anteriorly located AAPs situated <2 cm from the sternum are high-risk features that may complicate chest re-entry (5). The main intraoperative concerns are bleeding avoidance during sternotomy and maintenance of proper cerebral perfusion. Alternatively, in high-risk patients, endovascular therapies using stent grafts, coil embolization, thrombin injection, or occluder devices have the advantage of being less invasive, yet limitations remain (6). Multimodality imaging after aortic surgery enables the accurate diagnosis of such severe complications and helps determine the surgical plan. In our patient, it was repeated
on a 3-month interval basis postoperatively for the first year and yearly thereafter. Although CTA and MRA are useful diagnostic modalities, nephrotoxicity, radiation exposure (with CTA), and high costs (for MRA) limit their use as lifelong surveillance tools (7). It seems prudent to attempt to reduce the number of these exams per patient, depending on preoperative indication and surgical result. Our young patient who underwent a successful operation and had near-normal findings 1.5 year after surgery was scheduled for yearly TTE with a view to repeat MRA every 2e3 years.
Conflict of interest None declared.
References 1. Di Eusanio M, Berretta P, Bissoni L, Petridis FD, Di Marco L, Di Bartolomeo R. Re-operations on the proximal thoracic aorta: results and predictors of short- and long-term mortality in a
Please cite this article in press as: Bonou M, et al., Aortic root pseudoaneurysm causing hemodynamic and electrical instability very late after aortic valve repair, Hellenic Society of Cardiology (2017), http://dx.doi.org/10.1016/j.hjc.2017.06.001
+
MODEL
Letter to the Editor
2.
3.
4.
5.
6.
7.
series of 174 patients. Eur J Cardiothorac Surg. 2011;40: 1072e1076. Valero E, Santas E, Machado E, Nunez J. Pseudoaneurysm with fistulization to the lift atrium; a very late complication of previous aortic valve surgery. Int J Cardiol. 2016;212:145e147. Rallidis LS, Kelekis NL, Psaroyannakopoulos P, Antoniadis A, Anastasiou-Nana M. Multiple aortic pseudoaneurysms due to detachment of the composite graft after Bentall Operation. Hell J Cardiol. 2013;54:464e465. Perrotta S, Lentini S. Surgical management of severe damage of the aortic annulus. Hell J Cardiol. 2016. http://dx.doi.org/10. 1016/j.hjc.2016.11.012. Berretta P, Di Marco L, Pacini D, Cefarelli M, Alfonsi J, Castrovinci S, et al. Reoperations versus primary operation on the aortic root; a propensity score analysis. Eur J Cardiothorac Surg. 2017;51:322e328. Seratzis N, Melas N, Seratzis A, Lazaridis J, Kiskinis D. Minimally invasive endovascular intervention in emergent and urgent thoracic pathologies: single center experience. Hell J Cardiol. 2008;49(5):312e319. Katsargyris A, Verhoeven EL. Part two: against the motion. All TEVAR patients do not require lifelong follow-up by annual CTA/ MRA. [Con]. Eur J Vasc Endovasc Surg. 2012;44:538e541.
3 Maria Bonou, MD, PhD Eva D. Papadimitraki, MD, PhD * Department of Cardiology, Laiko General Hospital, Athens, Greece Fotios Mitropoulos, MD, PhD Andreas Karabinis, MD, PhD Onassis Cardiac Surgery Center, Athens, Greece George Anastasiadis, MD John Barbetseas, MD, PhD Department of Cardiology, Laiko General Hospital, Athens, Greece *Corresponding author. Eva D Papadimitraki, M.D., Ph.D., Department of Cardiology, Laiko General Hospital, 17 Agiou Thoma Street, 11527, Goudi, Athens, Greece. Tel.: þ30 2107456258; fax: þ30 2132061761. E-mail address: [email protected] (E.D. Papadimitraki) 26 February 2017
Please cite this article in press as: Bonou M, et al., Aortic root pseudoaneurysm causing hemodynamic and electrical instability very late after aortic valve repair, Hellenic Society of Cardiology (2017), http://dx.doi.org/10.1016/j.hjc.2017.06.001