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POST DOUBLE VALVE REPLACEMENT AORTIC PSEUDOANEURYSM
SUSHIL K. SINGH, Vivek Tewarson, Sarvesh Kumar, Kumar Rahul, Bhupendra Kumar, Mohammad Zeeshan Hakim;
King George's Medical University, LUCKNOW, India
BACKGROUND: Pseudoaneurysms following cardiac surgery is rare. Open surgical repair is the treatment of choice but it carries mortality up to 30% leading to the use of endovascular intervention to tackle this life-threatening problem.
We describe a case of ascending aortic pseudoaneurysm following a double valve replacement initially repaired using endovascular device, and later by emergent surgical repair due to persistent endo leak.
METHODS: A 27 year old female patient having double valve replacement (mechanical aortic and mitral valve) 1 ½ years back presented with pulsatile swelling at upper end of sternum. Trans thoracic, transesophageal echocardiography and contrast enhanced computed tomographic scan revealed a 5 cm diameter pseudoaneurysm in the ascending aorta. Sac opening was successfully closed by Amplatzer device.
She again developed a new pulsatile and painful swelling cranial to suprasternal notch 6 months after device closure. CECT aortogram revealed an increase in size of pseudoaneurysm ( 8 cm diameter ) and a leak as amplatz device was incompletely closing the sac opening. Surgical repair of pseudoaneurysm was planned. The procedure was carried out using femoro femoral cannulation and transient deep hypothermic circulatory arrest. After median sternotomy sac was opened and Amplatzer device was removed. An approximately 1cm
2 sized rent in the ascending aorta was closed with dacron pledgets using polypropylene sutures. Her postoperative course was uneventful.
RESULTS: With its high risk of rupture, a pseudoaneurysm requires an immediate operation when diagnosed. Despite the recent reports of percutaneously excluding false aneurysms, surgery is still necessary in large number of cases . Surgery has a high mortality due to fatal bleeding from rupture of a pseudoaneurysm upon sternal re-entry. Before resternotomy femoro-femoral bypass and deep hypothermia with transient circulatory arrest provides satisfactory results. In this case, aortic cross-clamping was possible on the distal ascending aorta which maintained cerebral perfusion.
CONCLUSIONS:Retrosternal Large pseudoaneurysm can cause massive bleeding from rupture during resternotomy. Femoro - femoral bypass with transient deep hypothermic arrest provides a safe option for surgery. Figure : Aortogram demonstrating Amplatzer ® device in-situ with endoleak and presence of a pseudo-sac arising from the proximal ascending aorta
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