Aortic pseudoaneurysm and rupture in a patient following aortic valve replacement with Saint Jude mechanical prosthetic valve

1. Ascending Aortic Pseudoaneurysm:
Post Aortic Valve Replacement
Dr SD Sanyal, Post Doctoral Trainee
Dr SS Mahapatra, Assoc Prof
Dept of CTVS
IPGME&R & SSKM Hospital

2. History
• 35 yr old lady presented with complaints of
swelling of the anterior aspect of chest x
10days :
- Sudden onset
- Gradually progressive
- Associated mild pain and burning sensation
- No h/o trauma, fever or other constitutional
symptoms suggestive of infective endocarditis

3. History
• Pt underwent Aortic valve replacement 5
months ago (SJ Bileaflet 23mm mechanical
prosthetic valve)
• Lesion was AS with AR
• On medication with tab Acitrom and Digoxin

4. Examination
• General examination:
BP: 146/90mmHg Pulse: 94/min/reg
RR:24/min/reg Temp: 98.4oF
Mild pallor+
• Local examination:
- 4x5 cm expansile swelling with every beat over
the body of the sternum on the left side
- Overlying skin normal
- Temperature normal
- Mildly tender

5. Examination
• Systemic examination:
- CVS: Diastolic murmur over the aortic area
- Chest: B/L vesicular breath sounds
- CNS/PA: NAD

6. Investigations
• Laboratory:
- Hb:9.1gm% TLC :5750/mm3
- Platelets: 1.4 lakhs Urea/creat: 22/0.7mg%
- Na/K: 130/4.5 mEq/L T.Bilirubin: 1.6mg/dl
- Alk PO4/OT/PT: 130/26/25
- T. Protein: 7.7gm/dl Albumin: 4.1gm/dl
- INR: 1.23
- APTT: Pt- 47.40/ Ct-30.00
- ASO/CRP: 114/37.9

7. Investigations
• Chest X-Ray PA view:
- Prominent convexity over the left heart border
with the shadow extending beyond the cardiac
silhouette
- Convexity over the right border which is well
delineated from the cardiac silhouette
• Lateral View:
- Complete obliteration of the retrosternal space
- Convex soft tissue swelling extending anterior to
the sternum

9. Investigations
• Echocardiography:
- Aneurysm of the ascending aorta extending
between the STJ and 1st Aortic branch
- Aneurysm has a narrow neck
- No flaps visualised in the descending and
abdominal aorta
- Paravalvular leak of moderate severity

10. Surgery
• Femoral artery and vein cannulated
• Right Axillary artery cannulation done with 6mm
dacron inter-position graft
• CPB initiated
• Gradual lowering of temp done
• Midline incision made over the sternum
• Sternotomy done with Oscillatory and normal
sternal saw
• Sac ruptured during sternotomy

15. Surgery
• Bleeding managed with placement of cardiotomy
suctions
• Right atrial cannulation done
• Head lowered and ice pack applied
• Thiopentone & steroid administered
• Monitoring with NIRS
• B/L Carotid compression
• TCA initiated
• Complete disruption of aortic suture line
• Area of defect approximately 3x4 cms
• Cross clamp applied over upper ascending aorta
• Ostial cardioplegia delivered and heart arrested

21. Surgery
• Region of paravalvular leak delineated between
the commissures of NCC and RCC
• There was no tissue ingrowth, pannus or
vegetation
• Leak closed with pledgeted Ethibond sutures
• Aortic margins trimmed
• Defect repaired with Bovine pericardial patch
using 5-0 Prolene sutures
• Patient weaned off CPB

24. Surgery
• Haemostasis achieved
• B/L pleural and 01 mediastinal drain placed
• Epicardial pacing wire placed over the RV
• Femoral artery and vein repaired after
decannulation
• Axillary artery decannulated and ligatures
placed over a residual stump of dacron graft

25. Post operative course
• Patient was shifted to ICU with ET tube in situ and
on ventilatory support
• Medications:
- Inj Meropenam
- Inj Teicoplanin
- Inj Lasix
- Inj UFH
- Inj Paracetamol
- Inj Ranitidine
- GTN infusion

26. Post operative course
• Patient extubated on POD1
• Drains removed on POD4
• Post operative systolic hypertension managed
with medicines

27. Post operative course
• Laboratory investigations:
- Hb: 10.8gm%
- TLC : 10370/mm3
- Platelets: 80000/mm3
- Urea/creat: 44/1.4mg%
- Na/K: 146/3.7 mEq/L
- T.Bilirubin: 3.6mg/dl
- Alk PO4/OT/PT: 51/17/141
- T. Protein: 6.1gm/dl
- Albumin: 3.1gm/dl
- INR: 1.23

28. Discussion

29. Aortic pseudoaneurysm
following AVR
• Definition:
- Post operative pseudoaneurysm of the
ascending aorta pertains to its dilatation and
disruption of one or more layers of the aortic wall
• Incidence:
- Extremely rare (0.6% after AVR)
- Higher for dilated aorta(27%)
- Overall incidence in cardiac surgery is 0.12-
0.35%

30. Aortic pseudoaneurysm
following AVR
• Pre-disposing factors:
- Older age
- Thin walled aorta
- Collagen vascular diseases
- Hypertension
- Severe atherosclerotic disease of the aorta
- Family h/o aortic disease
- Arteritis
- Aortic trauma due to instrumentation

31. Aortic pseudoaneurysm
following AVR
• Common sites of occurance:
- Aortic cannula site
- Cardioplegia cannula
- Position of the cross clamp
- Suture lines
• Mechanism:
- Disruption of suture lines
- Infection
- Jet flow
- Aortic fragility
- Extensive calcification

32. Aortic pseudoaneurysm
following AVR
• Time of presentation:
- Intra-operative
- Post-operative: 2 months to 17 years
• Clinical presentation:
- Retrosternal pain
- Radiation to back
- Hypotension
- New onset cardiac rhythm disturbances
- Sudden death

33. Aortic pseudoaneurysm
following AVR
• Diagnosis:
- Intra-operative:
1. Epi-aortic scan
2. TEE
* Importance:
- Immediate diagnosis
- Possibility of immediate surgical correction

34. Epi-aortic scan

35. Intra-op TEE

36. Aortic pseudoaneurysm
following AVR
- Post operative:
1. Chest X-Ray:
- Mediastinal widening
- Cheap and easily available

37. Chest X-Ray PA view

38. CT Imaging

39. CT Imaging

40. Cardiac MRI

41. Aortic pseudoaneurysm
following AVR
3. TTE:
- Dilated aortic root
- Peri-aortic echo free space with clot
- Colour flow imaging can demonstrate flow
into the pseudo-aneurysm
- Pulsed doppler to outline flow during systole
and diastole
- Cheap and available at bedside

43. Colour flow

44. Aortic pseudoaneurysm
following AVR
4. Aortogram:
- Invasive
- Use of Dye
- Good visualisation

46. Aortic pseudoaneurysm
following AVR
• Management:
- Planning the surgical approach:
# Midline sternotomy vs Anterolateral
thoracotomy
- Cannulation for CPB:
# Peripheral cannulation
# Carotid cannulation
# Temporary cessation of CPB

48. Aortic pseudoaneurysm
following AVR
- Hypothermic circulatory arrest
- Administration of cardioplegia
# Ostial vs Retrograde
- Prevention of LV distension
# Placement of intra-aortic balloon catheter
# LA venting by anterolateral thoracotomy
- Repair vs Replacement

49. Aortic pseudoaneurysm
following AVR
• Prevention:
- Intra-op diagnosis
- Prevention of infection
- Reinforcement of the aortic suture line
# Autologous pericardium
# Bovine pericardium
# Dacron, Teflon, Gortex

50. References
1. The use of autologous pericardium to reinforce the aorta suture in the surgical treatment of
the aortic valve.Marco Antonio Vieira Guedes; Pablo Maria Alberto Pomerantzeff; Carlos
Manuel de Almeida Brandão; Sérgio Almeida de Oliveira: Brazilian Journal of Cardiovascular
Surgery
2. Iatrogenic Aortic Pseudoaneurysm After an Aortic Valve Replacement Requiring Emergency
Reoperation:Elvera L. Baron, MD, PhD, Suraj D. Parulkar, MD†, Paul E. Stelzer, MD‡, Himani V.
Bhatt, DO, MPA, FASE. Journal of Cardiothoracic and Vascular Anaesthesia
3. Giant Aortic Pseudoaneurysm with Stanford Type A Aortic Dissection after Aortic Valve
Replacement: Mertay Boran,1 Ali İhsan Parlar,2 and Ertay Boran. Case Reports in Medicine
Volume 2012, Article ID 473732, 3 pages
4. Complications of Aortic Valve Surgery: Manifestations at CT and MR Imaging: Nancy
Pham, Hesham Zaitoun†, Tan Lucien Mohammed, Erasmo DeLaPena-Almaguer, Felipe
Martinez, Gian M. Novaro, Jacobo Kirsch . Published Online:Nov
2012https://doi.org/10.1148/rg.327115735

51. References
5. Diagnosis of Aortic Pseudoaneurysm by Echocardiography DAVID M. LASORDA, D.O.,
THOMAS P. POWER, M.B., SINDA B. DIANZUMBA, M.D., ROBERT L.kCORVATT, D.O.
Department of Medicine, Division of Cardiology, Medical College of PennsylvanidAllegheny
General Hospital, Pittsburgh, Pennsylvania, USA. Clin. Cardiol. 15,773-776 (1992)
6. Surgical Management of a Giant Ascending Aortic Pseudoaneurysm: Juan D. Garisto,
MD, Andres Medina, MD, Donald B. Williams, MD, and Roger G. Carrillo, MD. Tex Heart Inst J.
2010; 37(6): 710–713.
7. Management of ascending suture line sepsis by excision on the ascending aorta and insertion
of a left ventricular apex to aorta conduit. Krebber HJ, Hill JD, Szarnicki RJ. Thorac Cardiovasc
Surg. 1979 Dec;27(6):397-9
8. Long-Term Integrity of Teflon Felt-Supported Suture Lines in Aortic Surgery Justus T. Strauch,
MD, David Spielvogel, MD, Steven L. Lansman, PhD, Alexander L. Lauten, MS, Carol Bodian,
DPh, and Randall B. Griepp, MD

52. Thank You