|Year : 2013 | Volume
| Issue : 2 | Page : 62-64
Infected pseudoaneurysm of ascending aorta
Abdulhalim Jamal Kinsara, Faisal A Batwa, Areej Wazeer, Amjad Badawood
Department of Non-Invasive Cardiology, King Faisal Cardiac Center, King Saud Bin Abdulaziz University for Health Sciences, COM, King Abdul Aziz Medical City, Jeddah, Saudi Arabia
|Date of Web Publication||21-Sep-2013|
Abdulhalim Jamal Kinsara
King Faisal Cardiac Center, King Saud Bin Abdulaziz University for Health Sciences, COM, King Abdul Aziz Medical City, P.O. Box 9515, Jeddah 21423
Source of Support: None, Conflict of Interest: None
We are presenting a rare complication post Bioprosthetic aortic valve replacement. A middle age man presented with the clinical features of Pyrexia of unknown etiology and found out that he had endovascular infection, with septic emboli to the spleen. We are presenting two interesting images as a quiz and discuss in brief the clinical data of the infected pseudo aneurysm of the aortic root and ascending aorta.
Keywords: Ascending aorta, endovascular infection, pseudoaneurysm
|How to cite this article:|
Kinsara AJ, Batwa FA, Wazeer A, Badawood A. Infected pseudoaneurysm of ascending aorta. Heart India 2013;1:62-4
| Introduction|| |
Aortic pseudoaneurysm is a rare complication of postoperative cardiac valves surgery that may be infected or had a serious complication of rupture. It needs to be considered if there are signs of mediastinal infection. We are presenting a diagnostic images for a patient and highlight an over view of this condition.
| Case Report|| |
A 55-year-old male diabetic, status post-coronary artery bypass graft (CABG) and bioprosthetic aortic valve replacement (AVR) 1 year ago complained of fever with rigors of 1 month duration. No symptoms suggest a focal source and no recent upper respiratory tract infection. No symptoms of connective tissue disorders, recent travel or exposure to raw milk ingestion. Empirical course of antibiotics at the referring hospital was given and the patient was sent to us as pyrexia of undetermined origin.
Upon admission, he was febrile, stable hemodynamically, no clubbing or petechiae or vasculitis. Chest examination was clear with no murmurs or added sounds. Abdominal examination did not show organomegaly.
His primary investigations showed white cell count of 16.5 × 10^9/L. The blood cultures came back positive for Pseudomonas that was susceptible only to Meropenem and Amikacin, which was initiated on admission. His renal and liver functions were normal. Chest X-ray reveals sternotomy wire, AVR but no infection. Urine microscopy and cultures were negative.
Transthoracic echocardiogram was negative for valve infective endocarditis; however, the aortic root was dilated with suspicion of a mass at the aortic root; subsequently, transesophageal echocardiogram (TEE) was done.
Q1: What does the single and the double arrow point to? Noting that both aortic and mitral valves showed no abnormality [Figure 1].
Q2: What does the arrow in the computerized tomography (CT) chest and CT abdomen point to? [Figure 2].
A1: The double arrow points to a pseudocyst attached to the aortic root. While the single arrow points to the attached mobile masses suggestive of vegetation.
A2: The CT chest points to a vascular contrast filling structure attached to the aortic root and extends to the anterior wall of the proximal ascending aorta and is connected to its' lumen, measuring 38 mm. While the abdominal CT points to the presence of multiple hypodensities in the spleen suggestive of multiple infarcts.
In addition, both kidneys demonstrated wedge shaped hypodensity involving the upper poles.
Patient was treated as a case of endovascular infection. He was sent for surgical intervention and repair of infected pseudoaneurysm due to the presence of the multiple infarcts and the persistent bacteremia in spite of prolonged course of intravenous (IV) antibiotics of 6 weeks in our hospital. The operation was done after completion of an additional month of IV antibiotic and the operative findings were consistent with the clinical findings. Patient's fever settled after the surgery. His surgery consisted of resection of the saccular aneurysm, removing the infected material and repairing it with a pericardial patch. The aortic valve was clean and left with no intervention.
| Discussion|| |
An aneurysm is an abnormal focal arterial dilation. Aneurysms are classified into:
True: Covered by the three layers; Intima, media and adventitia or false: With a collection of blood or hematoma, which has leaked out of the artery, but is then confined by the surrounding tissue. 
Aortic pseudoaneurysms are rare but it is a life-threatening condition because of its serious complications mainly infection and rupture.
Many risk factors are encountered, the most important of which is cardiac surgery, with leaking at an aortic cannulation site or suture dehiscence or previous infection, mainly endocarditis.
Other less important causes include immune deficiency state, drug abuser and atherosclerotic artery. 
Infection of the pseudoaneurysm may be direct bacterial inoculation, with pre-existing aneurysms becoming secondarily infected and rupturing, hematogenous spread or contiguous infection from the surrounding. Commonly encountered organisms are Staphylococcus species (Methicillin-resistant Staphylococcus aureus) in 76%. And Salmonella More Details in 19%. Others are Streptococcus pneumoniae and Gram-negative organisms, which are associated with a higher incidence of rupture and mortality compared with Gram-positive organisms.
Pseudomonas aeruginosa is not an uncommon organism, especially after cardiac surgery as in our case. ,,
Three previous cases were reported from the same institution; however, two of them had AVR or AVR and MVR while the third had CABG only. In contrast our case had both AVR and CABG. ,
Most infected aortic pseudoaneurysms are asymptomatic unless they compress important structures. However, it may give non-specific signs and symptoms such as fever weight loss or chest pain. Other presentations include, peripheral embolism, manifestation of fistula or sudden rupture. 
Complete blood count might reveal leukocytosis and blood culture is positive in 50-75%.
TEE is very helpful and TEE has 86-100%, specificity 90-100% in detecting aortic aneurysm. 
Radiological investigation is useful; chest X-ray might show a wide mediastinum, while CT angiography is the most useful tool for the diagnosis of infected aneurysm. Magnetic resonance angiography is an alternative when CT is contraindicated to evaluate the aorta and coronary arteries.
A combination of medical and surgical interventions might be required for best treatment. Antibiotic therapy depends on the circumstances and blood culture result. Empirical therapy with vancomycin plus third generation cephalosporin (ceftriaxone) or tazobactam or fluoroquinolone to cover Gram-negative organisms, especially Salmonella and enteric Gram-negatives organism. 
In summary, infected aortic pseudoaneurysm is a rare cause of post-operative fever that needs to be considered if there are signs of mediastinal infection. Aggressive diagnostic and therapeutic steps need to be initiated promptly.
| Acknowledgments|| |
We would like to express our deep thanks and appreciation to Dr. Ashmeg AK and Dr. Abukhudair WA, Consultant Cardiac Surgeon, King Fahd Military Hospital, Jeddah for their help in managing patients and providing us with the surgical details.
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[Figure 1], [Figure 2]