European Journal of Echocardiography 2006 7(5):394-397; doi:10.1016/j.euje.2005.07.006
Copyright © 2005, The European Society of Cardiology
Infective endocarditis complicated by large aortic pseudoaneurysm after cardiac surgery
Nuno Jorge Pelicanoa,*,
Luísa Moura Brancoa,
Ana F. Agapitoa,
Spencer Salomãoa,
Luis Figueiredoa,
Jorge Cunhab,
A. Gomes da Cruzb,
João Luis Gouveiac,
José Roquetteb and
Jorge Quininhaa
aCardiology Department, Santa Marta Hospital – Lisbon, Portugal
bCardiothoracic Surgery Department, Santa Marta Hospital – Lisbon, Portugal
cInternal Medicine Department, Capuchos Hospital – Lisbon, Portugal
Received 29 December 2004; received in revised form 18 July 2005; accepted after revision 27 July 2005.
* Corresponding author. Hospital de Santa Marta – Lisbon, Department of Cardiology, Rua Professor Mira Fernandes Lote 1-1o Dto – 1900-386 Lisbon, Portugal. Tel.: +351218400039. nunopelicano{at}sapo.pt
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Abstract
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A 66-year-old female with
Streptococcus viridians aortic and
tricuspid infective endocarditis develops, during the course
of antibiotic therapy, rupture of a right coronary sinus of
Valsalva aneurysm to the right ventricle. An urgent cardiac
surgery is preformed with implantation of a mechanical aortic
prosthesis and a right coronary sinus plasty. Six months later
a huge aortic pseudoaneurysm is diagnosed and she is submitted
to a second uneventful surgery.
A review is done for the significant features with discussion of diagnosis and therapy.
Keywords: Sinus of Valsalva aneurysm; Thoracic aorta pseudoaneurysm; Infective endocarditis; Transthoracic echocardiography; Transesophageal echocardiography; Cardiac surgery
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Introduction
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Native valve infective endocarditis (IE) has well documented
predisposing factors, with high rates of morbidity and mortality.
1 A case is reported in which there was an infrequent complication
of IE – the rupture of a sinus of Valsalva aneurysm (SVA)
to the right ventricle (RV) – which needed a prompt diagnosis
and surgical therapy. A very rare complication of cardiac surgery
– an aortic pseudoaneurysm (PA) – was later on detected
and surgery had to be once again performed.
2 A description of
the clinical case and discussion of the relevant features are
performed.
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Clinical case
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A 66-year-old female patient, with a history of rheumatic fever
in childhood, complained in mid July 2000 of high fever (38–39°C),
chills and mental confusion. A craneoencephalic CT scan showed
multiple cerebral ischemic lacunar hypodensities. On 25th July
2000 she was admitted to the Hospital. A systolic cardiac murmur
was heard in the second right intercostal space. A transthoracic
echocardiogram (TTE) showed calcification of the aortic cusps,
with restricted opening, moderate aortic regurgitation and mild
mitral regurgitation. There was left ventricular hypertrophy.
No vegetations were identified. Normochromic, normocytic anemia
and leucocytosis with neutrophilia were detected and blood was
drawn for blood cultures. She was started on ciprofloxacin for
5 days due to an initial suspicion of urinary tract infection.
She was readmitted later on due to the maintenance of the febrile
syndrome. Another TTE and a transesophageal echocardiogram (TEE),
performed in the Cardiology Department of Santa Marta Hospital,
showed tricuspid valve vegetations and significant aortic valve
stenosis. (
Figs. 1 and 2
). Because of the great distortion of
the aortic valve no vegetations and/or peri-valvular abscess
were identified at that time. A later review of the tape showed
an anterior periaortic cavity that should correspond to an abscess.
There was no clear evidence of an SVA. Blood cultures were positive
for
Streptococcus viridians. Tricuspid and aortic valve IE were
diagnosed. The patient was started on Gentamicin and Penicillin
G iv and became afebrile on the 6th day. Subsequent blood cultures
were negative. On day 11, the patient complained of fatigue
and significant inferior limbs edema. There was hepatomegaly
and the cardiac murmur became continuous. A new TTE identified
a right SVA rupture to the RV (
Fig. 3). On 9th September 2000
she was submitted to cardiac surgery. Right SVA rupture to the
RV was confirmed. A mechanical prosthesis (St.Jude n°19
HP) was placed in aortic position and a right coronary sinus
plasty was performed. There were no immediate postoperative
complications. Seven further weeks of penicillin treatment were
done.
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Figure 1 Transesophageal echocardiography which shows a stenotic, very calcified aortic valve with no obvious vegetations, but with a image (A) that could be a periaortic valve abscess. (RA: Right atrium; LA: left atrium; RV: right ventricle; LV: left ventricle; AOV: aortic valve; AB: abscess).
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Figure 3 Transthoracic echocardiography which demonstrates a left to right shunt due to rupture of a sinus of Valsalva aneurysm to the right ventricle. (RA: Right atrium; RV: right ventricle; LA: left atrium; LV: left ventricle).
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During early follow-up she remained asymptomatic. In a routine
TTE, on March 2001, a cystic image that compressed the lateral
wall of the right atrium (RA) was detected (
Fig. 4), which on
TEE showed that it is connected to the aortic wall above the
prosthesis (
Fig. 5), which had a leak. A thoracic CT scan confirmed
the presence of a 9-cm saccular aneurysm of the aortic root,
which compressed the lateral wall of the RA.
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Figure 4 Transthoracic echocardiography that demonstrates a very large cystic image (PA) compressing the right atrium. (RA: Right atrium; RV: right ventricle; LA: left atrium; LV: left ventricle; PA: pseudoaneurysm).
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Figure 5 Transesophageal echocardiography that demonstrates a very large cystic image (AN) with a visible communication with the aortic root. (RA: Right atrium; LA: left atrium; LV: left ventricle; AO: aortic root; P: aortic mechanical prosthesis; PA: pseudoaneurysm).
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Although initially reluctant, she was readmitted to the Hospital
and was re-operated on 17th April 2001. The presence of an aortic
rupture just above the aortic valve plane was confirmed, communicating
with a very large PA, with migration of the right coronary artery
ostium. A conduit for reimplantation of the right coronary artery
had to be used. Aneurysmectomy, aortoplasty and suture of the
periprosthetic leak were also performed. Surgery and the immediate
recovery were uneventful and the patient was discharged asymptomatic.
After 40 months of follow-up she remains in NYHA class I, with
no further complications.
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Discussion
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The rupture of an SVA after IE is rare.
3 In the review done
by Anguera et al. from the Aorto-Cavitary Fistula in Endocarditis
Multicenter Study, 76 (1.6%) cases of aortocavitary fistula
(ACF) formation were detected in 4681 IE.
3 TTE is usually first
performed, but often TEE is needed. In the study by Anguera
et al. these techniques had a sensitivity of 53% and 97%, respectively,
for diagnosis.
3
The periaortic complications described here were not always immediately obvious: a previous diagnosis of tricuspid (and eventually aortic) valve IE was made in a patient with no known risk factors for right-sided IE and with concomitant severe aortic valve stenosis. Later on, as we referred, a new review of the TEE, demonstrated a cavity image that corresponded to a probable abscess anterior to the aortic ring. The sudden deterioration of the clinical parameters, with right cardiac failure and development of a new continuous heart murmur, was compatible with fistula formation. In this case, TTE immediately diagnosed this complication and the site of rupture of an SVA into the right ventricle. The patient initially refused to be submitted to a new TEE or to surgery and TEE was only performed at the time of surgery. It did not increase the accuracy of TTE.
Even more rare is the formation of a very large PA of the thoracic aorta as a complication of aortic valve IE,4 which in this case appeared after surgery. At first the correct diagnosis of this complication was not clear and the relationship between the huge cystic cavity near the lateral wall of the right atrium and the ascending aorta was not evident. Thoracic CT scan was very useful to better analyze and diagnose the abnormalities in the proximal ascending aorta, although TEE was also helpful. We believe that these two techniques should be performed in conjunction in cases of suspicion of thoracic aortic complications after aortic valve endocarditis. MRI may also give a good contribute to this diagnosis.
Surgical intervention in these cases is justified by the high risk of rupture even in the absence of symptoms.
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References
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- Karchmer A.W. IE. In: Heart disease: a textbook of cardiovascular medicine—Braunwald E., Zipes D., Libby P., eds. (2001) Philadelphia: WB Saunders Company. 1723–1750.
- De Almeida R.M.S., Lima J.D. Jr., Kahrbek T., Tanomaru M. Correcção cirúrgica de um pseudoaneurisma da aorta ascendente após troca valvar aórtica. Arq Bras Cardiol (2001) 76(4):326–328.[Medline]
- Anguera I., Miro J.M., Vilacosta I., et al. Aorto-cavitary fistulous tract formation in infective endocarditis: clinical and echocardiographic features of 76 cases and risk factors for mortality. Eur Heart J (2005 Feb) 26(3):288–297. [Epub 2004 Nov].[Abstract/Free Full Text]
- Tsai K.T., Cheng N.J., Chu J.J., Lin P.J. Aortic root pseudoaneurysm following surgery for aortic valve endocarditis. Chang Gung Med J (2002 Feb) 25(2):133–138.[Medline]
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Abstract
Introduction