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Pseudoaneurysm of the left ventricular outflow tract with reentry into the ascending aorta: an iatrogenic left ventricular ascending aortic fistula
Pseudoaneurysm of the Left Ventricular Outflow Tract with Reentry into the Ascending Aorta: An Iatrogenic Left Ventricular Ascending Aortic Fistula Benjamin Goldfarb, MD, Maya Rovner, MS, and Naomi Goldbraich, BA, Beer Sheva, Israel
We report a patient with an iatrogenic pseudoaneurysm o f the left ventricular outflow tract with reentry into the ascending aorta above the level o f a prosthetic aortic
valve. This pathology has not been previously described and was well demonstrated by transthoracic echocardiography. (J Am Soc Echocardiogr 1997;10:866-8.)
]["seudoaneurysm at the site o f an annulus-enlarging patch placed at the time o f aortic valve replacement has been previously described) We describe a unique case o f such a lesion with re-entry into the ascending aorta creating a left ventricular-ascending aortic fistula.
was replaced with a new number 19 St. Jude prosthesis, and the orifice of the pseudoaneurysm was obliterated. Postoperative echo Doppler examinations continued to show the same pseudoaneurysm with free entry of blood during systole, consistent with reopening of its orifice. In the short-axis transthoracic view, the pseudoaneurysm could be seen to arise from the area of the aortic ring between the left and non-coronary sinuses slightly posterior to the left main coronary artery orifice. It extended to the left, between the ascending aorta and the pulmonary artery and anterior to the left atrium, and could be seen to re-enter the left side of the ascending aorta above the level of the prosthetic valve, perhaps at the level of the distal suture line of the annulus enlarging Dacron patch (Figures 1, 2, and 3). There was free systolic flow in the pseudoaneurysm, but there was no significant diastolic flow. The patient was without symptoms at the time this article was written, and at that time no further intervention was planned.
CASE REPORT
In 1982 a 5-year-old boy had replacement of both mitral and aortic valves with Bjork prostheses because of severe rheumatic mitral and aortic regurgitation. Nine years later because of a large aortic systolic gradient and syncope, the patient underwent reoperation with implantation of a number 19 Sorin prosthesis in the aortic position and a number 29 Sorin prosthesis in the mitral position (tilting disc prostheses). The following year a new murmur of aortic insuffidency was detected, and on transthoracic echo-Doppler examination there was significant aortic regurgitation as well as an aneurysm-like structure seen between the posterior aortic wall and the left atrium. Within this structure color flow Doppler showed a pattern of systolic flow similar to that of the ascending aorta. Left ventriculography confirmed the presence of a pseudoaneurysm arising from the left ventricular outflow tract just below the sewing ring of the aortic prosthesis. At surgery the mechanism of aneurysm formation was found to be dehiscence of the annulusenlarging Dacron patch which had been placed in the area of the non-coronary sinus during the previous aortic valve replacement. The proximal suture line of this patch was the site of origin of the pseudoaneurysm. The aortic Sorin valve From the Cardiology Division, Soroka Medical Center, Faculty of Health Sciences Ben-Gurion University of the Negev. Reprint requests: B. Goldfarb, MD, Cardiology Division, Soroka Medical Center, Box 151, Beer Sheva 84105 Israel. Copyright © 1997 by the American Society of Echocardiography. 0894-7317/97 $5.00+0 27/4/81851 866
DISCUSSION
Pseudoaneurysm o f the left ventricular outflow tract at the site o f an aortic r o o t patch used to widen the aortic annulus at the time o f aortic valve replacement has been previously described? A characteristic picture o n transthoracic echocardiography (parasternal long- and short-axis views) shows the pseudoaneurysm between the aorta and the left atrium sometimes compressing the left atrium or even the p u l m o n a r y artery. ~ The same p a t h o l o g y has been reported a m o n g black Africans w i t h o u t previous surgery and may possibly be due to congenital weakness o f fibrous tissue below the aortic valve) I n cases o f aortic hom o g r a f t or composite graft placement a pseudoaneurysm may arise at the site o f the proximal suture line and may necessitate u r g e n t re-operation as a result o f compression o f the h o m o g r a f t by the enlarging pseu-
Journal of the American Society of Echocardiograpl~y Volume 10 Number 8
Goldfarb, Rovner, Goldbraich
867
Figure 1 Parasternal long-axis view. The pseudoaneurysm (P) is seen anterior to the left atrium (LA) and posterior to the ascending aorta (A). Aortic and mitral prosthetic valves are also seen. RV, Right ventricle; LV, left ventricle.
Figure 2 Parasternal short-axis view showing thc origin of the pscudoaneurysm (P) extcnding leftward from the left ventricular outflow tract, just below the prosthetic aortic valve, which is partially visualized in the figure. The left coronary artery (L) is seen just anterior to the pseudoaneurysm. LA, Left atrium; RV, right ventricle; PA, main pulmonary artery; A, distal left ventricular outflow adjacent to aortic annulus. doaneurysm. 2,3 Slightly below this area, the mitralaortic intervalvular fibrosa is also a site o f pseudoan~ eurysm formation, usually because of spread o f infection from aortic valve endocarditis (less commonly from blunt trauma). 4 The pseudoaneurysm
can rupture into the adjacent left atrium causing a fistula between the left ventricular outflow and the left atrium 4 (sometimes with extension into the interatrial septum causing an interatrial septal defect and interatrial shuntingS), or into the pericardium caus-
868
Journal of the AmericanSocietyof Echocardiography October 1997
Goldfarb, Rovner, Goldbraich
Figure 3 Parasternal short-axis view showing reentry site of the pseudoaneurysm into the ascending aorta above the level of the prosthetic valve. A, Ascending aorta. Other abbreviations as in Figure 2.
ing tamponade. It may also compress the left coronary artery and cause symptoms o f myocardial ischemia. 6 A n extension o f aortic valve endocarditis into the area o f the right coronary sinus (instead o f the area between the left and n o n - c o r o n a r y sinus) can enter the interventricular septum or right ventricle, whereas involvement o f the n o n - c o r o n a r y sinus can extend into the interventricular septum or into the right atrium. 7 At a slightly greater distance from the aortic annulus, a pseudoaneurysm o f the anterior mitral leaflet (also secondary to seeding and abscess formation from aortic valve endocarditis) can rupture into the left atrium causing atypical acute mitral insufficiency. 4 I n o u r patient the origin o f the pseudoaneurysm was at the site o f the proximal suture line o f an annulus-enlarging D a c r o n patch placed at the n o n - c o r o n a r y sinus with reentry into the ascending aorta, possibly at the distal suture line o f the same patch. T h e p a t h o l o g y was well demonstrated by transthoracic echocardiography w i t h o u t the necd o f a transesophage.al approach. O n color flow D o p p l e r there was free systolic flow from the left ventricular outflow tract into the pseudoaneurysm and subsequently into the ascending aorta. H o w e v e r , diastolic rcturn flow was n o t seen, implying a " o n e way valve" effect somewhere along the structure's course. T h e site o f origin o f the pseudoaneurysm is very close to the left main coronary artery. Fortunately, to this date
there have been no symptoms o f myocardial ischemia. T o our knowledge there is no previously reported case o f such a defect. Because o f the patient's asymptomatic state and the fear o f technical difficulties in an area scarred from three previous surgeries, no further intervention is planned at this time.
REFERENCES
1. SkoularigisJ, Deviri E, Wisenbaugh T, Essop R, Middlemost S, Sareli P. Role oftransesophageal echocardiography in diagnosis of subaortic aneurysm. Am J Cardiol 1992 ;69:1102 -4. 2. Oechslin E, Carrel T, Ritter M, et al. Pseudoaneurysmfollowing aortic homograft: clinicalimplications?Br Heart J 1995;74:645-9. 3. Barbetseas J, Crawford E, Sail H, Coselli J, Quinones M, Zoghbi W. Doppler echocardiographic evaluation of pseudoaneurysms complicating composite grafts of the ascending aorta. Circulation 1992;85:212-22. 4. Karalis D, Bansal R, Hanck A, et al. Transesophageal echocardiographic recognition of subaortic complications in aortic valve endocarditis. Clinical and surgical implications. Circulation 1992;86:353-62. 5. Sheppard R, Chandrasekaran K, Ross J, Mintz G. An acquired interatrial fistula secondary to para-aortic abscess documented by transesophageal echocardiography. J Am Soc Echocardiography 1991;4:271-6. 6. Bier A, Lamphere J, Daily P. Coronary artery compression caused by a large pseudoaneurysm of the mitral-aortic intervalvular fibrosa. J Am Soc Echocardiography 1995;8:753-6. 7. Weyman A. Principles and practice ofechocardiograph. 2nd ed. Philadelphia: Lea and Febiger, 1994;1189.
We report a patient with an iatrogenic pseudoaneurysm o f the left ventricular outflow tract with reentry into the ascending aorta above the level o f a prosthetic aortic
valve. This pathology has not been previously described and was well demonstrated by transthoracic echocardiography. (J Am Soc Echocardiogr 1997;10:866-8.)
]["seudoaneurysm at the site o f an annulus-enlarging patch placed at the time o f aortic valve replacement has been previously described) We describe a unique case o f such a lesion with re-entry into the ascending aorta creating a left ventricular-ascending aortic fistula.
was replaced with a new number 19 St. Jude prosthesis, and the orifice of the pseudoaneurysm was obliterated. Postoperative echo Doppler examinations continued to show the same pseudoaneurysm with free entry of blood during systole, consistent with reopening of its orifice. In the short-axis transthoracic view, the pseudoaneurysm could be seen to arise from the area of the aortic ring between the left and non-coronary sinuses slightly posterior to the left main coronary artery orifice. It extended to the left, between the ascending aorta and the pulmonary artery and anterior to the left atrium, and could be seen to re-enter the left side of the ascending aorta above the level of the prosthetic valve, perhaps at the level of the distal suture line of the annulus enlarging Dacron patch (Figures 1, 2, and 3). There was free systolic flow in the pseudoaneurysm, but there was no significant diastolic flow. The patient was without symptoms at the time this article was written, and at that time no further intervention was planned.
CASE REPORT
In 1982 a 5-year-old boy had replacement of both mitral and aortic valves with Bjork prostheses because of severe rheumatic mitral and aortic regurgitation. Nine years later because of a large aortic systolic gradient and syncope, the patient underwent reoperation with implantation of a number 19 Sorin prosthesis in the aortic position and a number 29 Sorin prosthesis in the mitral position (tilting disc prostheses). The following year a new murmur of aortic insuffidency was detected, and on transthoracic echo-Doppler examination there was significant aortic regurgitation as well as an aneurysm-like structure seen between the posterior aortic wall and the left atrium. Within this structure color flow Doppler showed a pattern of systolic flow similar to that of the ascending aorta. Left ventriculography confirmed the presence of a pseudoaneurysm arising from the left ventricular outflow tract just below the sewing ring of the aortic prosthesis. At surgery the mechanism of aneurysm formation was found to be dehiscence of the annulusenlarging Dacron patch which had been placed in the area of the non-coronary sinus during the previous aortic valve replacement. The proximal suture line of this patch was the site of origin of the pseudoaneurysm. The aortic Sorin valve From the Cardiology Division, Soroka Medical Center, Faculty of Health Sciences Ben-Gurion University of the Negev. Reprint requests: B. Goldfarb, MD, Cardiology Division, Soroka Medical Center, Box 151, Beer Sheva 84105 Israel. Copyright © 1997 by the American Society of Echocardiography. 0894-7317/97 $5.00+0 27/4/81851 866
DISCUSSION
Pseudoaneurysm o f the left ventricular outflow tract at the site o f an aortic r o o t patch used to widen the aortic annulus at the time o f aortic valve replacement has been previously described? A characteristic picture o n transthoracic echocardiography (parasternal long- and short-axis views) shows the pseudoaneurysm between the aorta and the left atrium sometimes compressing the left atrium or even the p u l m o n a r y artery. ~ The same p a t h o l o g y has been reported a m o n g black Africans w i t h o u t previous surgery and may possibly be due to congenital weakness o f fibrous tissue below the aortic valve) I n cases o f aortic hom o g r a f t or composite graft placement a pseudoaneurysm may arise at the site o f the proximal suture line and may necessitate u r g e n t re-operation as a result o f compression o f the h o m o g r a f t by the enlarging pseu-
Journal of the American Society of Echocardiograpl~y Volume 10 Number 8
Goldfarb, Rovner, Goldbraich
867
Figure 1 Parasternal long-axis view. The pseudoaneurysm (P) is seen anterior to the left atrium (LA) and posterior to the ascending aorta (A). Aortic and mitral prosthetic valves are also seen. RV, Right ventricle; LV, left ventricle.
Figure 2 Parasternal short-axis view showing thc origin of the pscudoaneurysm (P) extcnding leftward from the left ventricular outflow tract, just below the prosthetic aortic valve, which is partially visualized in the figure. The left coronary artery (L) is seen just anterior to the pseudoaneurysm. LA, Left atrium; RV, right ventricle; PA, main pulmonary artery; A, distal left ventricular outflow adjacent to aortic annulus. doaneurysm. 2,3 Slightly below this area, the mitralaortic intervalvular fibrosa is also a site o f pseudoan~ eurysm formation, usually because of spread o f infection from aortic valve endocarditis (less commonly from blunt trauma). 4 The pseudoaneurysm
can rupture into the adjacent left atrium causing a fistula between the left ventricular outflow and the left atrium 4 (sometimes with extension into the interatrial septum causing an interatrial septal defect and interatrial shuntingS), or into the pericardium caus-
868
Journal of the AmericanSocietyof Echocardiography October 1997
Goldfarb, Rovner, Goldbraich
Figure 3 Parasternal short-axis view showing reentry site of the pseudoaneurysm into the ascending aorta above the level of the prosthetic valve. A, Ascending aorta. Other abbreviations as in Figure 2.
ing tamponade. It may also compress the left coronary artery and cause symptoms o f myocardial ischemia. 6 A n extension o f aortic valve endocarditis into the area o f the right coronary sinus (instead o f the area between the left and n o n - c o r o n a r y sinus) can enter the interventricular septum or right ventricle, whereas involvement o f the n o n - c o r o n a r y sinus can extend into the interventricular septum or into the right atrium. 7 At a slightly greater distance from the aortic annulus, a pseudoaneurysm o f the anterior mitral leaflet (also secondary to seeding and abscess formation from aortic valve endocarditis) can rupture into the left atrium causing atypical acute mitral insufficiency. 4 I n o u r patient the origin o f the pseudoaneurysm was at the site o f the proximal suture line o f an annulus-enlarging D a c r o n patch placed at the n o n - c o r o n a r y sinus with reentry into the ascending aorta, possibly at the distal suture line o f the same patch. T h e p a t h o l o g y was well demonstrated by transthoracic echocardiography w i t h o u t the necd o f a transesophage.al approach. O n color flow D o p p l e r there was free systolic flow from the left ventricular outflow tract into the pseudoaneurysm and subsequently into the ascending aorta. H o w e v e r , diastolic rcturn flow was n o t seen, implying a " o n e way valve" effect somewhere along the structure's course. T h e site o f origin o f the pseudoaneurysm is very close to the left main coronary artery. Fortunately, to this date
there have been no symptoms o f myocardial ischemia. T o our knowledge there is no previously reported case o f such a defect. Because o f the patient's asymptomatic state and the fear o f technical difficulties in an area scarred from three previous surgeries, no further intervention is planned at this time.
REFERENCES
1. SkoularigisJ, Deviri E, Wisenbaugh T, Essop R, Middlemost S, Sareli P. Role oftransesophageal echocardiography in diagnosis of subaortic aneurysm. Am J Cardiol 1992 ;69:1102 -4. 2. Oechslin E, Carrel T, Ritter M, et al. Pseudoaneurysmfollowing aortic homograft: clinicalimplications?Br Heart J 1995;74:645-9. 3. Barbetseas J, Crawford E, Sail H, Coselli J, Quinones M, Zoghbi W. Doppler echocardiographic evaluation of pseudoaneurysms complicating composite grafts of the ascending aorta. Circulation 1992;85:212-22. 4. Karalis D, Bansal R, Hanck A, et al. Transesophageal echocardiographic recognition of subaortic complications in aortic valve endocarditis. Clinical and surgical implications. Circulation 1992;86:353-62. 5. Sheppard R, Chandrasekaran K, Ross J, Mintz G. An acquired interatrial fistula secondary to para-aortic abscess documented by transesophageal echocardiography. J Am Soc Echocardiography 1991;4:271-6. 6. Bier A, Lamphere J, Daily P. Coronary artery compression caused by a large pseudoaneurysm of the mitral-aortic intervalvular fibrosa. J Am Soc Echocardiography 1995;8:753-6. 7. Weyman A. Principles and practice ofechocardiograph. 2nd ed. Philadelphia: Lea and Febiger, 1994;1189.