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J Thorac Cardiovasc Surg 1995;110:1143-1144
© 1995 Mosby, Inc.

BRIEF COMMUNICATIONS

ACQUIRED AORTOPULMONARY FISTULA IN PSEUDOANEURYSM OF THE AORTA SIX YEARS AFTER A BENTALL OPERATION

Philippe Chevalier, MD, Enrique Moncada, MD, Gilbert Kirkorian, MD, Paul Touboul, MD


Lyon, France

From Hôpital Cardiovasculaire et pneumologique Louis Pradel, Lyon, France.

Pseudoaneurysm of the ascending aorta is a rare and serious complication after composite graft surgery for combined disorder of the aortic valve and ascending aorta. Go 1 Rupture of these pseudoaneurysms usually results in death caused by tamponade. In this article, we present an exceptional case of pseudoaneurysm of the ascending aorta complicated by fistulization into the pulmonary artery trunk.

A 72-year-old woman was admitted to our hospital with dyspnea for 3 weeks. Six years before she had undergone a Bentall-DeBono procedure involving a composite conduit with a mechanical valvular prosthesis. At this time, there was no clinical evidence of Marfan syndrome, but aortic parietal biopsy showed signs of cystic medial necrosis. The symptoms began suddenly with constrictive anterior chest pain associated with hemoptysis and progressive congestive heart failure. On admission the patient had marked dyspnea with orthopnea. Physical findings included cyanosis and a rough grade 4/6 continuous murmur maximal at the second right intercostal space. Blood pressure was 100/60 mm Hg on both arms. Electrocardiogram showed sinus rhythm with normal conduction.

Two-dimensional echocardiography showed good left ventricular contraction and a large eccentric pseudoaneurysm of the ascending aorta arising from a dehiscence at the distal aortic anastomosis. Doppler echocardiography showed an important systolic and diastolic flow from the ascending aorta into the truncus pulmonalis.

At aortography, the aortic root appeared markedly dilated and contrast medium passed from the ascending aorta to the proximal part of the pulmonary artery (Fig. 1).



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  		Fig. 1. Aortography lateral view. Pigtail catheter in ascending aorta. Passage of contrast directly from aortic root to pulmonary artery.

 
Four hours after admission the patient underwent thoracotomy. The ascending aorta was dilated to a maximum diameter of 10 cm just above the coronary arteries down to the origin of the brachiocephalic artery. Total dehiscence at the distal aortic anastomosis was found. A communication of 1.5 cm in diameter between the aneurysm and right pulmonary artery was seen. The opening in the pulmonary wall was closed with a pericardial patch. The aorta was reconstructed with a Dacron graft. The patient subsequently had an uncomplicated recovery but died after 14 days of a sudden cardiac arrest.

The composite graft method for replacement of the aortic valve and ascending aorta has become a widely accepted procedure, but it carries a potential risk of various late complications. Go 2 Among these is the development of pseudoaneurysm of the ascending aorta as a result of dehiscence of the suture line at the aortic anulus or distal graft anastomosis. Usually, with the rupture of the aortic wall, the effusion of blood takes place in the pericardial space, and to our knowledge fistulization between the pseudoaneurysm and the pulmonary artery has never been described.

This observation supports the concept that early detection and aggressive treatment of a diseased aorta may improve long-term survival after the Bentall operation. It is particularly true when weakening of the aortic wall is likely to be more rapid, that is, when gross medial disease is present. Go 3 Furthermore, the importance of full-thickness suturing at the distal anastomosis of the aortic Dacron graft in case of annuloaortic ectasia should be noted. Go 4

Footnotes

J THORAC CARDIOVASC SURG 1995;110:1143-4 Back

References

  1. Kouchoukos N, Marshall William G Jr, Wedige-Stecher T. Eleven-year experience with composite graft replacement of the aorta and aortic valve. J THORAC CARDIOVASC SURG 1986;92:691-705.[Abstract]
  2. Kazuhiro T, Susumu N, Hikaru M. Long-term survival and complications after composite graft replacement for ascending aortic aneurysm associated with aortic regurgitation. Circulation 1991;84(Suppl):III31-9.
  3. Gott VL, Pyeritz RE, Magovern GJ, Cameron DE, McKusick VA. Surgical treatment of aneurysms of the ascending aorta in the Marfan syndrome: results of composite-graft repair in 50 patients. N Engl J Med 1986;314:1070-4.[Abstract]
  4. Cabrol C, Pavie A, Mesnildrey P. Long-term results with total replacement of the ascending aorta and reimplantation of the coronary arteries. J THORAC CARDIOVASC SURG 1986;91:17-25.[Abstract]



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