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| LETTER TO THE EDITOR |
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| Year : 2020 | Volume
: 4
| Issue : 3 | Page : 92-93 |
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Ticking bomb inside the thoracic cavity
Monish S Raut
Department of Cardiac Anesthesia, Artemis Hospital, Gurgaon, Haryana, India
| Date of Submission | 03-Jun-2020 |
| Date of Acceptance | 19-Aug-2020 |
| Date of Web Publication | 29-Sep-2020 |
Correspondence Address:
Dr. Monish S Raut
Department of Cardiac Anesthesia, Artemis Hospital, Gurgaon, Haryana
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/hm.hm_23_20
How to cite this article:
Raut MS. Ticking bomb inside the thoracic cavity. Heart Mind 2020;4:92-3 |
A 38-year-old gentleman presented with chest pain and parasternal bulge for the past 6 months. He had a history of double-valve replacement (aortic and mitral) 2 years back. Echocardiographic examination showed large aneurysmal dilation of the ascending aorta on the lateral aspect [Figure 1]. Computed tomography (CT) aortogram revealed a large pseudoaneurysm arising 1.6 cm above the sinotubular junction on the lateral aspect. Ostium of the pseudoaneurysm was 1.9 cm in size with huge false aneurysm compressing superior vena cava and right pulmonary artery. The pseudoaneurysm seemed to perforate through the sternum. The patient also had nodular cirrhosis of the liver with occlusion of the right hepatic vein and the intrahepatic inferior vena cava with resultant Budd–Chiari syndrome. The patient was scheduled for the device closure of aortic defect in cardiac catheterization laboratory. Under fluoroscopic and transesophageal echocardiographic guidance, occluding device HeartR XJFS18 (Lifetech Scientific) was successfully deployed across the ostium of pseudoaneurysm. No significant flow across the aortic rent was observed. After few days, CT aortogram was repeated which revealed leak around the device and increase in the aneurysm size [Figure 2]. The patient was scheduled for surgical repair of the aortic aneurysm. After uneventful anesthesia induction, femoral arteriovenous cardiopulmonary bypass was commenced. Deep hypothermic circulatory arrest at 18°C was established. After sternotomy and dissecting dense adhesions, aorta was identified and cross-clamped. Aortic perforation was repaired using a portion of collagen-coated vascular graft. The patient could be weaned from cardiopulmonary bypass with minimal inotropic support in hemodynamically stable condition. Postoperative course of the patient was uneventful with good neurological function and hemodynamically recovery. | Figure 1: (a) Parasternal swelling on the chest wall. (b) Echocardiographic image showing the dimensions of aortic pseudoaneurysm (6.6 cm × 7.4 cm). (c) Chest X-ray showing shadow of aortic pseudoaneurysm marked by arrow
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 | Figure 2: (a) Computed tomography showing large ascending aortic pseudoaneurysm. (b) Computed tomography showing large ascending aortic pseudoaneurysm. (c) Echocardiographic image showing pseudoaneurysm compressing superior vena cava. (d) Computed tomography showing aortic pseudoaneurysm filled with contrast even after occluding device placement
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Thoracic aortic pseudoaneurysm is an exceedingly uncommon complication after cardiac surgery observed in <0.5% of patients.[1] Morbidity and mortality rates in such cases have been reported from 29% to 46%.[2] Pseudoaneurysms of the ascending aorta postaortic valve replacement generally occur at aortic cannulation or aortotomy or anastomotic suture lines.[3]
Presentation of the aortic pseudoaneurysm can be elusive. Considering its high fatality rate, it acts as a ticking bomb in the chest. When open surgical therapy cannot be performed in high-risk patients, minimally invasive catheter-based device closure of the ascending aortic pseudoaneurysm can be considered as a life-saving option.[4],[5],[6],[7] Although the experience is limited, successful transcatheter closure of the ascending aortic pseudoaneurysm has been reported in patients having prohibitive surgical risk factors.[8] Proper planning and multimodality comprehensive imaging such as three-dimensional printing technology are essentially needed for such complex structural interventions. Vigilance is certainly warranted in patients with the possibility of infectious aortitis. Absolute closure of aortic pseudoaneurysm is of paramount importance, or else persistent residual leak is enough to keep the pseudoaneurysm patent.
Lesser invasive percutaneous intervention using device closure of such aneurysm can be preferred, but surgical option should always be ready in case of failure of device closure.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Katsumata T, Moorjani N, Vaccari G, Westaby S. Mediastinal false aneurysm after thoracic aortic surgery. Ann Thorac Surg 2000;70:547-52.  |
| 2. | Attia R, Venugopal P, Whitaker D, Young C. Management of a pulsatile mass coming through the sternum. Pseudoaneurysm of ascending aorta 35 years after repair of tetralogy of Fallot. Interact Cardiovasc Thorac Surg 2010;10:820-2. |
| 3. | Parihar B, Choudhary LS, Madhu AP, Alpha MK, Thankachen R, Shukla V. Pseudoaneurysm of ascending aorta after aortic valve replacement. Ann Thorac Surg 2005;79:705-7. |
| 4. | Hussain J, Strumpf R, Wheatley G, Diethrich E. Percutaneous closure of aortic pseudoaneurysm by Amplatzer occluder device-case series of six patients. Catheter Cardiovasc Interv 2009;73:521-9. |
| 5. | Kanani RS, Neilan TG, Palacios IF, Garasic JM. Novel use of the Amplatzer septal occluder device in the percutaneous closure of ascending aortic pseudoaneurysms: A case series. Catheter Cardiovasc Interv 2007;69:146-53. |
| 6. | Lyen SM, Rodrigues JC, Manghat NE, Hamilton MC, Turner M. Endovascular closure of thoracic aortic pseudoaneurysms: A combined device occlusion and coil embolization technique in patients unsuitable for surgery or stenting. Catheter Cardiovasc Interv 2016;88:1155-69. |
| 7. | Kumar PV, Alli O, Bjarnason H, Hagler DJ, Sundt TM, Rihal CS. Percutaneous therapeutic approaches to closure of cardiac pseudoaneurysms. Catheter Cardiovasc Interv 2012;80:687-99. |
| 8. | Tang L, Lesser JR, Gössl M, Burns MR, Schneider LM, Schwartz JG, et al. Transcatheter closure of complex ascending aortic pseudoaneurysms after cardiac surgery. Circ Cardiovasc Interv 2018;11:e007052. |
[Figure 1], [Figure 2]
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