Aortic Pseudoaneurysm Complicated by Aortopulmonary Fistula
A 78-year-old woman presented with an abrupt onset of chest pain and dyspnea. Fourteen years before admission, she had undergone aortic root and valve replacement with the Bentall-de Bono continuous-suture wrap-inclusion technique because of an aneurysm of the ascending aorta and severe aortic valve regurgitation. Physical examination revealed signs of congestive heart failure and poor peripheral perfusion. The admission radiograph (Figure 1) showed lung congestion predominantly in the right lung, bilateral pleural effusion, elevation of the left hemidiaphragm, tracheal shift to the right side, and aortic arch calcification. The ECG (Figure 2) revealed sinus tachycardia at 111 bpm, frequent premature atrial beats, and repolarization abnormalities that consisted of T-wave inversion in the inferolateral leads. Transthoracic echocardiography showed a hypertrophied left ventricle with normal systolic function. Computed tomography disclosed a huge pseudoaneurysm of the ascending aorta (maximum diameter 7 cm) surrounding and compressing the aortic graft (Figure 3); a saccular protrusion of the pseudoaneurysm into the right pulmonary artery was also identified. Transesophageal echocardiography demonstrated systolic collapse of the prosthetic aortic graft (Figure 4A; Movie). In addition, a communication was noted between the pseudoaneurysm and the right pulmonary artery that resulted in a large aortopulmonary shunt (Figure 4B).
The patient was rejected for surgery and died of multiorgan failure 48 hours after admission. Autopsy showed an extensive dehiscence of the proximal and distal aortic graft suture and confirmed the diagnosis of a huge aortic pseudoaneurysm that compressed the aortic graft (Figure 5), as well as the presence of an aortopulmonary fistula (Figure 6).
Pseudoaneurysm of the ascending aorta and aortopulmonary fistula is a relatively unusual but potentially fatal complication that occurs after surgery of the ascending aorta with the use of the continuous-suture wrap-inclusion technique.1,2 In this technique, the diseased aorta is replaced by a Dacron graft by use of a continuous-suture technique at the anastomosis, and the native aorta wall is wrapped around the aortic graft.
The online-only Data Supplement is available with this article at http://circ.ahajournals.org/cgi/content/full/CIRCULATIONAHA.108.815928/DC1.