Continuous Murmur After Ascending Aortic Surgery
We report a case of an aortic root pseudo aneurysm (PSA) that ruptured into the right pulmonary artery (RPA) causing a large left-to-right shunt and congestive heart failure. A 56-year-old man presented with New York Heart Association class III congestive heart failure 6 years after insertion of a Freestyle aortic valve bioprosthesis with reimplantation of the coronaries as button anastomoses to treat a localized aortic root dissection. Physical examination demonstrated a grade 4/6 continuous murmur at the left sternal border, bibasilar crackles, left lung base dullness, ascites, and pedal edema. Chest x-ray (portable anteroposterior film, Figure 1) showed marked cardiomegaly, prominent pulmonary vasculature, and a left pleural effusion suggestive of left ventricular volume overload. Twelve-lead ECG (Figure 2) showed sinus rhythm, biatrial enlargement, and biventricular hypertrophy with right ventricular strain pattern. The above findings were suspicious for a chronic hemodynamically significant left-right shunt. Transthoracic echocardiography identified a 35×49-mm PSA posterior to the aortic root (Figure 3; online-only Data Supplement Movie I). Color Doppler suggested that the PSA originated from the area of the left coronary artery button/ascending aorta anastomosis. (Figure 4; online-only Data Supplement Movie II). Continuous flow in the RPA suggested that the PSA had fistulized to the pulmonary arterial tree with left-to-right shunting, (Figure 5; online-only Data Supplement Movie III), but this distal rupture site could not be clearly demonstrated. Transesophageal echocardiography confirmed the proximal tear site (Figure 6; online-only Data Supplement Movie IV) but failed, as well, to demonstrate the distal fistulous site. Sixty-four-slice cardiac computed tomographic angiography demonstrated the full extent of the PSA with both the proximal and distal tear sites (Figures 7 and 8⇓). It also demonstrated left-to-right shunting into the RPA (see negative contrast in Figure 9). The patient underwent successful surgical repair, at which time the cardiac computed tomographic angiography findings were confirmed (Figure 10).
In conclusion: When a patient is seen in congestive heart failure with continuous murmur after ascending aortic surgery, an aortopulmonary fistula should be considered. Cardiac computed tomographic angiography offers superior diagnostic capabilities in these complex postoperative patients. In our case, cardiac computed tomographic angiography clarified pathology that was incompletely demonstrated by echocardiography and allowed surgical correction without invasive diagnostic testing such as aortography.
The online-only Data Supplement is available with this article at http://circ.ahajournals.org/cgi/content/full/119/1/e1/DC1.