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Mycotic aneurysm formation with dehiscence of a valved aortic conduit resulting in dynamic aortic obstruction
  1. N R A CLARKE,

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A 67 year old man presented with acute breathlessness, sharp chest pain radiating to the back on swallowing, and a two month history of “flu like” symptoms. One year previously he had undergone elective implantation of a 25 mm Carboseal valved aortic conduit for severe aortic regurgitation caused by annulo-aortic ectasia. Blood pressure was 85/60 mm Hg, temperature was 38°C, and there was a harsh ejection systolic murmur and a quiet aortic diastolic murmur. Transthoracic echocardiography revealed an 8 cm mycotic false aneurysm around the aortic conduit and cranial systolic displacement of the valve by up to 1 cm. Transoesophageal echocardiography confirmed proximal dehiscence of the valved conduit with vegetations but no valvar regurgitation and a large mycotic abscess. During systole, false aneurysm pressure exceeded aortic pressure, leading to collapse of the aortic conduit and generation of a dynamic pressure gradient of 100 mm Hg (top) (LVOT, left ventricular outflow tract; A, false aneurysm; L, conduit lumen). In diastole, falling pressure in the false aneurysm restored the normal lumen of the conduit (bottom). There was a small amount of retrograde diastolic flow into the aneurysm at the distal suture line in the mid ascending aorta.

At emergency surgery, the valved prosthesis was almost completely dehissed from the annulus, with extensive vegetations. The outer wall of the false aneurysm was formed from fibrous tissue and laminated thrombus, and there was a small defect in the distal aortic suture line. An aortic homograft was inserted successfully. Multiple blood cultures grew Propionibacterium species sensitive to penicillin, and the patient was discharged after six weeks of antibiotic treatment.