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A 52 year old man with aortic regurgitation caused byStreptococcus mutans endocarditis underwent aortic valve replacement with a 23 mm Medtronic Hall aortic valve prosthesis. Six years later he presented with exertional chest pain associated with a positive exercise test. A posteroanterior chest x ray showed a soft tissue bulge at the right mediastinum.
Computed tomography (A) demonstrated a 13 cm pseudoaneurysm of the thoracic aorta. The lumen contains contrast medium but is largely obliterated by thrombus, and there is erosion of the sternum. At aortography, contrast was injected into the pseudoaneurysm demonstrating a narrow neck arising from the aorta in close proximity to the aortic valve prosthesis (B). Coronary angiography showed no evidence of intrinsic coronary artery disease; however, the proximal portion of the right coronary artery was compressed extrinsically by the pseudoaneurysm.
The patient underwent surgical repair of the pseudoaneurysm using extrathoracic bypass. The cause of the aneurysm appeared to be failure of the aortotomy suture line. Having mobilised the aneurysm sac the defect in the aortotomy suture line was repaired with buttressed sutures. Postoperative progress was uneventful and all antianginal treatment was discontinued. Four years later the patient remains well with normal effort tolerance.