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© 2004 European Association of Cardio-Thoracic Surgery
Asymptomatic pseudoaneurysm of the ascending aorta diagnosed due to accompanying infection of a right atrial embolusDivision of Cardiothoracic Surgery, University of Alberta, Edmonton, Alta, Canada
* Corresponding author. Department of Cardiac Surgery, University of Munich, Klinikum Augustinum, Wolkerweg 16, 81375 Munich, Germany. Tel.: +49-89-7097-1817; fax: +49-89-7097-1848 Received July 7, 2003; received in revised form September 17, 2003; accepted September 21, 2003
We present a case of a large pseudoaneurysm of the ascending aorta, originating from the purse-string suture of the cardioplegia line which was essentially asymtomatic but was diagnosed during patient follow up for fever and elevated white blood count of unknown origin. During intraoperative transesophageal echocardiography, a free floating tumor was localized in his right atrium which after removal appeared to be an infected embolus with excessive neutrophils and monocytoid cells interspersed with cell debris and fibrin. Material send for culture was positive for streptococci, whereas tissues cultures from the pseudoaneurysm were essentially negative. To our knowledge, this is the first report of an asymtomatic, non-infected aortic pseudoaneurysm which was accidentally diagnosed due to concomitant infection of an deep venous thrombus which had embolized into the right atrium.
Key Words: Aortic pseudoaneyrysm; Deep venous thrombosis; Infection The development of an ascending aortic pseudoaneurysm following coronary artery bypass grafting (CABG) with the use of cardiopulmonary bypass is a rare complication and has been described previously. Depending on its location it usually presents with severe symptoms of myocardial ischemia including chest pain and shortness of breath on exertion. We present an unusual case of a large pseudoaneurysm of the ascending aorta, originating from the purse-string suture of the cardioplegia line which was essentially asymtomatic but was diagnosed during patient follow up for fever and elevated white blood count of unknown origin. This 72 year old gentlemen was advanced for elective CABG to our Department in November 2000. At this time a CABGx4 was performed with left internal mammary artery to left anterior descending coronary artery and three reversed saphenous vein grafts to first diagonal, obtuse marginal and posterior descending coronary artery. His postoperative period was uneventful. He was exercising frequently and the patient was discharged on postoperative day 4 in stable sinus rhythm on routine anticoagulation with Aspirin 81 mg daily. In July 2002 he underwent a dental cleaning and developed episodes of recurrent fever 3 weeks later. Blood cultures revealed streptococci in clumps and he was treated with antibiotics and referred to his cardiologist for further investigation. Upon transesophageal echocardiography (TEE) an approximately 5x4 cm perfused lesion was noted on the anterior aspect of his ascending aorta. Subsequent computed tomography (CT) of the chest showed an ascending aortic aneurysm which after 3-D reconstruction revealed to be a true pseudoaneurysm (Fig. 1). He was referred to us for surgery with the diagnosis of an infected pseudoaneurysm.
During surgery in August 2002 the pseudoaneurysm was identified and its entry closed with a 2x2 cm bovine pericardial patch. Tissue was send to pathology and microbiology for further diagnosis. During intraoperative TEE, a 5 cm in length measuring free floating tumor was localized in his right atrium. Upon removal this material appeared to be an old deep venous thrombus (DVT), possibly embolizing from his deep leg veins. Histopathological examination revealed a thrombus with excessive neutrophils and monocytoid cells interspersed with cell debris and fibrin. Material send for culture was positive for streptococci, whereas tissues cultures from the pseudoaneurysm were essentially negative. In addition, the aortic tissue send for histopathologic examination was tested by our pathologists. The tissue was scanned meticulously because of the presence of an infected embolous in the same patient. However, the tissue of the pseudoneurysm did not reveal histopathologic signs for bacterial infection. The patients postoperative course was uneventful. He was discharged home on postoperative day 5 and kept on intravenous antibiotics for another 6 weeks. To our knowledge, this is the first report of an asymptomatic, non-infected aortic pseudoaneurysm which was accidentally diagnosed due to concomitant infection of an deep venous thrombus which had embolized into the right atrium. It appears very unusual that under the clinical circumstances the pseudoaneurysm remained free from infection. However, previous reports have demonstrated that the development of pseudoaneurysms are associated with their infection. In this regard, Garfin et al. was one of the first who described an infected aortic pseudoaneurysm associated with cannulation sites for cardiopulmonary bypass [1]. Despite the risk for intravascular sepsis, aortic pseudoaneurysms may be symptomatic by compressing nearby structures such as right ventricle or atrium [2]. Another unusual finding in the present report is the infected right atrial embolus. Indeed, the co-incidence between the patients dental appointment and occurrence of fever suggests that this was the most likely cause of initial bacteremia with subsequent infection of the right atrial emboli. From pathologic findings, there is no obvious relationship between the right atrial embolus and the development of the pseudoaneurysm. The connection would have been an infection of both or a secondary infection of one due to the presence of the other. This can not be completely ruled out. However, it is surprising that the pseudoneurysm remained non-infected in the presence of a large infected atrial embolous. Importantly, the clinical symptoms of the patient appear to be primarily from systemic infection with streptococci, however, the size and location of the pseudoaneurysm per se was a clear indication for surgical intervention. As to the literature, most infected atrial thrombi are associated with foreign materials including central venous catheters, ports or pacemaker devices as well as atrial fibrillation, none of which the patient had. Even though the time course of DVT development remains uncertain, the present report suggests, that under conditions of major surgical trauma optimal anticoagulation should be considered beyond the initial postoperative in-hospital period [3]. doi:10.1016/S1569-9293(03)00223-8
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