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Year : 2009  |  Volume : 12  |  Issue : 2  |  Page : 152-153
Large pseudoaneurysm of aortic root after aortic valve replacement for rheumatic heart disease: A rare complication


1 Department of Anaesthesiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum - 695 011, Kerala, India
2 Department of Imaging Sciences and Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum - 695 011, Kerala, India

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Date of Web Publication21-Jul-2009
 

How to cite this article:
Misra S, Koshy T, Patro SN, Dash PK. Large pseudoaneurysm of aortic root after aortic valve replacement for rheumatic heart disease: A rare complication. Ann Card Anaesth 2009;12:152-3

How to cite this URL:
Misra S, Koshy T, Patro SN, Dash PK. Large pseudoaneurysm of aortic root after aortic valve replacement for rheumatic heart disease: A rare complication. Ann Card Anaesth [serial online] 2009 [cited 2020 Dec 1];12:152-3. Available from: https://www.annals.in/text.asp?2009/12/2/152/53444


A 25-yr-old male, weighing 66 kg s, with a height of 175 cm s presented with hemoptysis since six months. Other relevant history included aortic valve replacement (25 mm Medtronic-Hall tilting disc valve) three years back for rheumatic aortic regurgitation. A right paracardiac opacity was seen in continuation with mediastinal shadow on chest x-ray (CXR) [Figure 1]. Computed tomography (CT) scan of chest revealed a large right para-aortic pseudoaneurysm with layered clots and a small residual lumen communicating with the aortic root [Figure 2] and [Figure 3]. Transthoracic echocardiography (TTE) showed aneurysm extending from sino-tubular junction to the aortic arch with good prosthetic valvular function. There was no evidence of intra- cardiac vegetation. The aneurysm was repaired on extra-thoracic femoro-femoral cardiopulmonary bypass with a short duration of circulatory arrest [Figure 4].

Pseudoaneurysm of the aorta is a rare but potentially fatal complication, with an incidence of one per cent following aortic surgery. [1],[2] Dehiscence of suture sites or inflammatory processes affecting previous aortotomy or cannulation sites can result in disruption of one of the layers of the aortic wall, which is then contained by other layers of the aorta or the mediastinum. Since the heart and great vessels lie in the middle mediastinum, the differential diagnosis of middle mediastinal masses include enlarged pulmonary artery, pericardial cysts, foregut duplication cysts (bronchogenic, esophageal, neurenteric), tracheal lesions and lymphadenopathy.

CXR is often a starting point in the evaluation of mediastinal masses. Accurate localization of mediastinal abnormality narrows the differential diagnosis and helps to determine appropriate further imaging. [3] Features on CXR in favour of middle mediastinal masses are obliteration of hilum, loss of convexity of aorto-pulmonary (AP) window (the AP window is bounded by the aortic arch superiorly and the pulmonary artery inferiorly and is normally concave or straight) and obliteration of right paratracheal stripe (right paratracheal stripe is seen projecting through the superior vena cava and is formed by the trachea, mediastinal connective tissue, and paratracheal pleura. It is visible due to the air-soft tissue interfaces on either side).

CT and magnetic resonance imaging are used to define the extent and location of mediastinal masses and also to rule out the involvement of other intra-thoracic structures. Furthermore, they delineate abnormalities in the proximal ascending aorta more precisely compared to transesophageal echocardiography. [4] However, echocardiography is a better modality to differentiate between aortic root abscesses and true aneurysm. [5]

A high index of suspicion and use of multiple imaging modalities is required for diagnosing pseudoaneurysm of the aorta as symptoms may be minimal or absent. Surgical intervention is justified in these cases due to a high risk of rupture. Intra-operative lung isolation by the use of double- lumen endotracheal tubes may be contemplated in case the aneurysm erodes lung parenchyma.

 
   References Top

1.Sullivan KL, Steiner RM, Smullens SN, Griska L, Meister SG. Pseudoaneurysm of the ascending aorta following cardiac surgery. Chest 1988;93:138-43.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Fedriga E, Diehl L, Paganini V, Morello M. Diagnostic imaging of aortic pseudoaneurysm: s0 tudy of 4 clinical cases. Cardiologia 1996;41:661-5.  Back to cited text no. 2  [PUBMED]  
3.Whitten CR, Khan S, Munneke GJ, Grubnic S. A diagnostic approach to mediastinal abnormalities. Radiographics 2007; 27:657-71.  Back to cited text no. 3    
4.Pelicano NJ, Branco LM, Agapito AF, Salomγo S, Figueiredo L, Cunha J, et al . Infective endocarditis complicated by large aortic pseudoaneurysm after cardiac surgery. Eur J Echocardiogr 2006;7:3 94-7.  Back to cited text no. 4    
5.Lobato EB, McKenzie ED, Beaver TM. Intraoperative diagnosis of aortic pseudoaneurysm with transesophageal echocardiography. J Clin Monit Comput 1999;15:53-5.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]

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Correspondence Address:
Satyajeet Misra
Department of Anaesthesiology, Flat B-6, NFH, SCTIMST Institute Quarters, Poonthi Road, Kumarapuram, Trivandrum - 695 011, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.53444

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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