Eur J Cardio-thorac Surg (l 996) 10:705-706
© Springer-Verlag 1996
M. F e d e r m a n n
L. K. von Segesser
M. Ritter
R. Jenni
Received: 6 October 1995
Accepted: 24 November 1995
M_ Federmann - M. Ritter - R. Jenni ([])
Department of Echocardiography,
University Hospital,
CH-8091 Ztirich, Switzerland
L. K. von Segesser
Department of Cardiothoracic Surgery,
University Hospital,
CH-8091 Ztirich, Switzerland
Spontaneous obliteration of a
pseudo-aneurysm complicating an
aortic homograft
Abstract Pseudoaneurysm formation after aortic homograft replacement in patients with active endocarditis is a c o m m o n observation and
usually occurs at the site of a former
abscess or paravalvular leak in case
of prosthetic valve endocarditis.
A 53-year-old man with prosthetic
endocarditis underwent aortic valve
homograft replacement and developed a pseudoaneurysm at the right
and noncoronary aortic sinus which
was documented by Doppler echo-
cardiography. Follow-up examination ten months after operation unexpectedly revealed a complete obliteration of the previously echo free
space between the homograft and the
native aortic root and, thus, spontaneous obliteration of the pseudoaneurysm. [Eur J Cardio-thorac Surg
(1996) 1 0 : 7 0 5 - 7 0 6
K e y w o r d s Pseudoaneurysm Aortic homograft • Endocarditis.
Doppler echocardiography
Introduction
Case report
Aortic homograft implantation is currently the surgical
therapy of choice for active aortic valve endocarditis [2].
P s e u d o a n e u r y s m formation can result from partial dehiscence o f the aortic homograft especially at the proximal
suture line and is usually located in the area of a former
abscess or paravalvular leak [3]. Visualization of an echofree space between the homograft and the native aortic root
which is perfused from the left ventricular outflow tract is
diagnostic for p s e u d o a n e u r y s m in Doppler echocardiography and is observed at follow-up in up to 73% of patients
[3], The clinical relevance of this entity is not well known,
h o w e v e r lethal hemorrhage caused by a rupture [1] and severe homograft compression requiring reoperation [3, 4]
have been described_ Moreover, there is a potential risk for
embolism and recurrent infection. We report spontaneous
obliteration of a paravalvular aortic pseudoaneurysm.
A 53-year-old man was admitted to our hospital for prosthetic valve
endocarditis caused by Staphylococcus epidermidis. Six years before, a 27 mm Omnicarbon aortic prosthesis had been implanted following endocarditis of the bicuspid native aortic valve with Streptococcus mutans. Despite appropriate antibiotic treatment, abscess formation with progressive paravalvular aortic insufficiency developed.
The infected prosthesis was therefore replaced by a 23 mm aortic homograft after removal of the infected material. The proximal suture
line and the dead space between the homograft and the native aortic
root were sealed with fibrin glue as previously described [5]. Two
days postoperatively a transthoracic Doppler echocardiographic examination revealed a clinically asymptomatic hemispherical pseudoaneurysm adjacent to the right and non-coronary aortic sinus at
the site of the former paravalvular leak. At discharge 3 weeks later
the size of the pseudoaneurysm had moderately increased with some
compression of the homograft (Fig., left) and continued to exhibit
the typical systolic inflation by blood arising from the left ventricular outflow tract_ Antibiotic treatment was given until 3 months after operation, antithrombotic therapy was stopped at discharge. Follow-up examination 10 months postoperatively, unexpectedly, dem-
706
onstrated complete obliteration of the pseudoaneurysm with thickening of the right and non-coronary aortic root wall (Fig., right).
To our k n o w l e d g e , this is the first report o f spontaneous
obliteration o f an aortic h o m o g r a f t p s e u d o a n e u r y s m ,
w h i c h is p r o b a b l y due to local t h r o m b o s i s and c o n s e c u t i v e
shrinking. The clinical course in this patient supports our
current a p p r o a c h o f watchful waiting, if an aortic p s e u d o a n e u r y s m is found on p o s t o p e r a t i v e e c h o c a r d i o g r a p h i c examination, with r e o p e r a t i o n only if p r o g r e s s i v e enlargem e n t o f the p s e u d o a n e u r y s m and/or severe v a l v u l a r dysfunction o c c u r s . T h e i n t r a o p e r a t i v e use o f fibrin glue seems
to decrease the overall i n c i d e n c e o f p s e u d o a n e u r y s m s [5],
but was not p r e v e n t i v e in the present case.
Fig. 1 Short axis views of the aortic root. Left sickle-shaped pseudoaneurysm (P) surrounding the homograft (H) in the area of the
right and non-coronary cusp. Right thickening of the aortic wall following spontaneous obliteration of the pseudoaneurysm
References
1. Donaldson RM, Ross DM (1984)
Homograft aortic root replacement for
complicated prosthetic valve endocarditis. Circulation 70 [Suppl I]: 178-181
2. Haydock D, Baratt-Boyes B, Macedo T,
Kirklin JW, Blackstone E (1992) Aortic
valve replacement for active infectious
endocarditis in 108 patients. A comparison of freehand allograft valves with
mechanical prostheses and bioprostheses. J Thorac Cardiovasc Surg
103:130-139
3. Oechslin E, Carrel T, Ritter M, Attenhofer C, Von Segesser L, Turina M,
Jenni R (1995) Pseudoaneurysm following aortic homograft: clinical implications? Br Heart J 74:645-649
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RE Almassi GH (1992) Periaortic
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