SHA24/025006

SURGICAL REPAIR AND OUTCOME OF LARGE MYCOTIC PSEUDO-ANEURYSM OF THE ASCENDING AORTA ORIGINATING AT SAPHENOUS VEIN GRAFT TAKE OFF SITE

Mohamed F. Ibrahim FRCS (C/Th) , Ayman Sallam MD, Samih Lawand, MD, Fahad S. Al Ghofaili, FRCSC.

Cardiac Surgery Department, Prince Salman Heart Center, King Fahad Medical City

INTRODUCTION

• Mediastinitis after median sternotomy is a

devastating complication of cardiac surgery

• Mycotic pseudo-aneurysm of an artery is

defined as bacterial or fungal endarteitis with erosion of the inner layers of the arterial wall

INTRODUCTION

• The mechanisms involved in the development of mycotic pseudo-aneurysm:

An inflammatory process around the aorta such as

deep wound infection or mediastinitis, can spread to and invade the wall of the aorta

Endothelial damage of the ascending aorta at

anastomosis or cannulation site can also initiate an infectious process

INTRODUCTION

• The site of aortic cannulation is the most commonly involved, followed by the anastomotic suture lines

• Pseudo-aneurysm of the ascending aorta is

considered an urgent or emergent surgical priority and carries high operative morbidity and mortality

Berkmen YM.1986 Raven press:161-

CASE PRESENTATION

• A 55-year-old gentleman who is diabetic and

hypertensive, he was transferred to our heart center from his local hospital with ACS.

• He had •

positive nasal and axillary swabs for

MRSA His EF was 35-40%. He underwent an urgent CABG X 3

• He was on inotropic support in the immediate

postoperative period for LCO and stayed in ICU for three nights

CASE PRESENTATION

• His remaining hospital stay was uneventful and was discharged home after 10 days.

• He was readmitted 2 weeks later with lower

sternal wound infection (pseudomonas and MRSA). He was treated by IV antibiotics and VAC pump for two weeks and then discharged home after all cultures became negative.

CASE PRESENTATION

• The patient was re-admitted one week later

with recurrent sternal wound infection and was started on Vancomycin and Ceftazidine

• During his work up  Cultures and wound swabs were negative  

Elevated CRP at 140 Chest x-ray

CHEST X-RAY

CASE PRESENTATION • He started to have haemoptysis • He had a CT scan of his chest with contrast

CASE PRESENTATION • He became feverish and started to have haemoptysis • CT scan of his chest with contrast • TTE and TEE

TTE & TEE

CASE PRESENTATION • He became feverish and started to have haemoptysis • CT scan of his chest with contrast • TTE and TEE • Cardiac Catheterization and coronary angiogram

CASE PRESENTATION MANAGEMENT PLAN • Percutaneous closure • Surgical repair

CASE PRESENTATION

CASE PRESENTATION

CASE PRESENTATION POST-OPERATIVE RECOVERY

• The patient’s post-operative course was uneventful

POST OPERATIVE CT SCAN

CASE PRESENTATION POST-OPERATIVE RECOVERY

• The patient received 6 weeks course of IV

antibiotics (gm –ve bacilli from pleural fluid) and was discharged from the hospital in good condition

• He was seen in the outpatient clinic one year

after discharge enjoying good health, without any evidence of recurrent infections.

DISCUSSION & CONCLUSION

•

Infectious mediastinitis after median sternotomy needs at least 6 weeks of IV antibiotics

•

Some reports described percutaneous closure of large pseudo-aneurysms of the ascending aorta with an Amplatzer occluder device *, stent grafts, and coils *

•

Surgical repair is the conventional treatment but associated with high mortality

Stasek J, Can J Cardiol. 2008;24(12):99-101.

Fann JI.J Vasc Surg2002;35:811-4.

DISCUSSION & CONCLUSION

• For mycotic pseudo-aneurysms of ascending

aorta after cardiac surgery, the early diagnosis, aggressive surgical treatment, appropriate antibiotic therapy and close follow-up by radiographic studies are mandatory in managing patients with this potentially fatal condition.

THANK YOU