Case Report Abstract
My Most Interesting Case – Cardiology
Late complication of a previous Bentall’s procedure – a large compressive pseudo-aneurysm of the aortic composite graft
A 73 year old, hypertensive female who in 2012 had undergone a Bentall’s procedure with a replacement of the aortic root and ascending aorta using a 21mm BioValsalva composite graft for a 7cm ascending aortic aneurysm with moderate aortic regurgitation.
For a year following this surgery good symptomatic improvement had been made, and LV function on echocardiography improved to normal. However there remained a persistent aortic regurgitation of moderate severity, which by the end of 2013 had become severe with developing symptoms of heart failure. On CXR a new bulging opacity was noted along the left heart border.
CT scanning and transoesophageal echocardiography revealed a large pseudo-aneurysm due to a 1cm partial dehiscence of the proximal aortic suture line. Compression and distortion of the aortic prosthesis by the large aneurysm was causing severe AR and aortic stenosis, as well as left atrial compression.
Case discussed in the joint cardiology/cardiothoracic meeting and agreed for redo surgery but the adhesions from the previous surgery were of concern.
Discussion of what was actually done and the challenges, deaths and complications encountered.
Following cardiopulmonary bypass the patient was cooled to 18C in anticipation of requiring circulatory arrest. A vent was inserted into the LV apex. Despite the previous surgery the sternum was divided uneventfully and the dense adhesions around the heart were dissected initially with no problems. Bicaval bypass was commenced. The pericardial space was insufflated with CO2, the aneurysm was entered and the dehiscence in the non-coronary sinus was located and repaired using 2/0 Prolene sutures. There was significant haemorrhage from the apical vent during repair requiring sutures, Teflon felt and BioGlue and excessive blood loss into the drains from the adhesions at the back of the heart, which were controlled with packing with large swabs. The procedure was completed with no further complications but the chest was not closed until 2 days later.
Post-operatively recovery was slow, with a long period of inotropes and Dressler’s syndrome. She was discharged over a month later to another hospital for on-going rehabilitation.