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Mycotic pseudoaneurysm of the ascending aorta following aortic valve replacement

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A 71 year old woman presented with lethargy and weakness. One year previously she underwent aortic valve replacement for symptomatic aortic stenosis with a Carpentier–Edwards pericardial valve. Her admission temperature was 101.4°F (38.6°C) and subsequent blood cultures grew methicillin resistant Staphylococcus aureus. Transoesophageal echocardiography (top) revealed an echo free bilobed space (arrow) originating from the ascending aorta approximately 2 cm above the level of the aortic annulus. The pseudoaneurysm was surrounded by increased echogenicity consistent with inflammation (LA, left atrium). Chest computed tomography (middle) revealed an abscess cavity (arrow) in communication with the proximal ascending aorta (“A”), with contrast extravasation into the abscess cavity surrounded by a large area of mediastinal inflammatory consolidation.

At surgery a large active pseudoaneurysm abscess cavity originating from the old aortotomy suture line was found (bottom). Surgical approach included femoral–femoral cardiopulmonary bypass, with careful repeat sternotomy and dissection of the proximal ascending aorta allowing for cross clamping at the level of the innominate artery take off. The aorta was opened laterally, allowing identification of the origin of the pseudoaneurysm at the medial start site of the previous aortotomy, approximately 2 cm above the aortic annulus. The abscess cavity contained fresh pus and clotted blood. The abscess and involved aortic wall was debrided, and the ascending aorta was reconstructed by patch aortoplasty using cryopreserved homograft aorta. The bioprosthetic valve did not appear to be involved in the infectious process, and was left in situ.

Following omentoplasty and chest closure the patient was extubated and had an uneventful early postoperative course. Unfortunately she died from complications related to a pulmonary embolus two weeks later.