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J Thorac Cardiovasc Surg 1997;114:138-139
© 1997 Mosby, Inc.

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ULTRAFAST COMPUTED TOMOGRAPHY IN INFECTIOUS PSEUDOANEURYSM OF THE LEFT VENTRICULAR OUTFLOW TRACT

Browns Mills New Brunswick, N.J.

From the Department of Thoracic and Cardiovascular Surgery, Deborah Heart and Lung Center, Browns Mills, N.J., and UMDNJ-Robert Wood Johnson Medical School, New Brunswick, N.J.

Received for publication Jan. 20, 1997 accepted for publication Jan. 28, 1997. Address for reprints: William K. Anderson, MD, Deborah Heart and Lung Center, 200 Trenton Rd., Browns Mills, NJ 08015.

Infectious pseudoaneurysm of the left ventricular outflow tract is a potentially catastrophic complication of aortic and mitral valve surgery. Successful surgical management relies on knowledge of the exact location and extension of the pseudoaneurysmal cavity and involvement of the mitral-aortic intervalvular fibrosa. ¹ We describe a case of infectious pseudoaneurysm occurring 4 years after aortic valve replacement for Streptococcus endocarditis. The pseudoaneurysmal cavity extended laterally and posteriorly from the left coronary cusp, inferior to the pulmonary artery and lateral and superior to the wall of the left atrium, left ventricle, and left ventricular outflow tract. Diagnostic evaluation consisted of echocardiography, right heart catheterization, coronary angiography, and ultrafast computed tomography (CT). The latter facilitated the surgical repair by providing a dynamic, three-dimensional picture of the pseudoaneurysmal cavity and its relationships with adjacent structures.

Clinical summary.
A 40-year-old man was referred to the hospital 4 years after aortic valve replacement with a 25 mm St. Jude Medical valve (St. Jude Medical, Inc., St. Paul, Minn.) for Streptococcus viridans endocarditis. Two months before admission, the patient had shortness of breath, recurrent fever, and confusion. A transesophageal echocardiogram (TEE) revealed a cavity adjacent to the left side of the aortic anulus. CT scan revealed splenic infarcts, renal embolism, hepatomegaly, and right pleural effusion. Blood cultures grew Staphylococcus aureus. Sodium nafcillin was given intravenously for 6 weeks with subsequent negative blood cultures. One month before admission an echocardiogram revealed deformity of the aortic root consistent with a cavity that compressed the pulmonary artery and expanded during systole. Doppler echocardiography showed flow into and out of the cavity. Ultrafast CT revealed a well-seated aortic prosthesis with the ring at the aortic anulus. Administration of contrast material demonstrated a periannular cavity tracking posteriorly and inferiorly, extending laterally over the top of the left atrium (Fig. 1). Pulmonary capillary wedge pres sure was 22 mm Hg and pulmonary artery pressure was 50/30 mm Hg. The aortogram revealed one plus central aortic regurgitation without perivalvular leak. Coronary arteriography revealed dynamic obliteration of the left anterior descending and circumflex coronary arteries with a smooth, proximal high-grade stenosis during systole and returning to normal during diastole. Levophase showed dilatation of the left atrium with a communication between the left ventricular outflow tract and a large pseudoaneurysm.

View larger version (97K): [in this window] [in a new window]   Fig. 1. Ultrafast CT scan demonstrating extension of the pseudoaneurysm around the pulmonary artery and the left atrium. Ao, Aorta; PA, pulmonary artery; PsA, pseudoaneurysm; RV, right ventricle; SVC, superior vena cava.

Discussion.
Surgical treatment of infectious pseudoaneurysm of the left ventricular outflow tract consists of debridement of all nonviable tissue, exclusion of the periannular cavity from the circulation, firm closure of the cavity by direct suture or patch closure, and reconstruction of the aortic anulus to provide adequate seating of the prosthetic valve. ² The most common site for development of an infectious pseudoaneurysm is the mitral-aortic intervalvular fibrosa. ¹ TEE has become the diagnostic procedure of choice for noninvasive evaluation of prosthetic valves. It provides a two-dimensional image across the heart and quantifies flows and pressures across the valves and between the heart chambers, the great vessels, and the pseudoaneurysm. A left ventriculogram may demonstrate an intervalvular pseudoaneurysm but is often not obtained because doing so implies crossing the prosthetic aortic valve. ^3,4 Although coronary artery disease is infrequent in the age group of patients with infectious endocarditis, dynamic coronary obstruction by a pseudoaneurysm has been documented. ⁵ The combination of aortic regurgitation and dynamic coronary obstruction may cause severe myocardial ischemia with coronary blood flow reduced during diastole and systole.

Ultrafast CT scan has the advantage of sequentially demonstrating all chambers of the heart after a single intravenous administration of contrast material, providing a dynamic, three-dimensional picture of the aortic area and ventricular cavities. In the present case, ultrafast CT demonstrated the pseudoaneurysmal cavity and its relationship with the left ventricular outflow tract, left atrium, pulmonary artery, and the aortic root.

In summary, we advocate routine use of ultrafast CT scanning in the diagnosis of valve endocarditis suspected to involve the mitral-aortic intervalvular fibrosa or the aortic anulus. The combination of ultrafast CT with TEE provides an accurate picture of the relationship of the pseudoaneurysm to adjacent structures and may obviate the need for ventriculography. Coronary arteriography should be used selectively in patients with symptoms of myocardial ischemia to demonstrate concomitant coronary disease or document dynamic coronary obstruction.

References

1. Karalis DG, Bansal RC, Hauck AJ, et al. Transesophageal echocardiographic recognition of subaortic complications in aortic valve endocarditis: clinical and surgical implications. Circulation 1992;86:353-62.[Abstract/Free Full Text]
   
2. Watarabz G, Haverich S, Spier R, et al. Surgical treatment of active endocarditis with paravalvular involvement. J Thorac Cardiovasc Surg 1994;107:171-7.[Abstract/Free Full Text]
   
3. Afridi I, Apostolidou MA, Saad RM, et al. Pseudoaneurysms of the mitral-aortic intervalvular fibrosa: dynamic characterization using transesophageal echocardiographic and Doppler techniques. J Am Coll Cardiol 1995;24:137-45.
   
4. Jault F, Gandjbakhch I, Chastre JC, et al. Prosthetic valve endocarditis with ring abscesses: surgical management and long-term results. J Thorac Cardiovasc Surg 1993;105:1106-13.[Abstract]
   
5. Parashara DK, Jacobs LE, Kotler MN, et al. Angina caused by systolic compression of the left coronary artery as a result of pseudoaneurysm of the mitral-aortic intervalvular fibrosa. Am Heart J 1995;129:417-21.[Medline]
   

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This Article Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Luis D. Berrizbeitia William A. Anderson Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Berrizbeitia, L. D. Articles by Anderson, W. A. Search for Related Content PubMed PubMed Citation Articles by Berrizbeitia, L. D. Articles by Anderson, W. A.