Asian Cardiovasc Thorac Ann 2006;14:83-84
© 2006 Asia Publishing EXchange Ltd
IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY |
Delayed Pseudo-Aneurysm of Right Coronary Artery after Indirect Reimplantation
Mathias H Aazami, MD
Department of Cardiac Surgery, CHU-Brabois, Vandoeuvres les-Nancy, France
For reprint information contact: Mathias H Aazami, MD Tel: 33 1 4346 5339 Fax: 33 1 4346 5339 Email: mathias.aazami{at}laposte.net, 126 rue de Picpus, Paris 75012, France
A 47-year-old non-Marfan patient with annuloectasia (74mm), grade IV aortic regurgitation and previous episode of cardiac decompensation had undergone electively wrap-inclusion composite valve grafting with indirect reimplantation of each coronary ostium by interposition of 8-mm Dacron graft (Mills type operation). The patient was reoperated on the same day for bleeding and no surgical leakage was noted. Eight months later and after an uneventful postoperative recovery period, he was presenting with rapid worsening of his functional capacity. The chest radiogram revealed a mediastinal widening with a prominent superior-right outline (Figure 1
). Transthoracic echocardiography demonstrated a peri-prosthetic collection with a maximum supra-valvular gradient of 40 mm Hg. Thoracic computed tomography showed a large heterogenous haematoma within and outside inclusion wrap, with leakage of contrast in the area of right coronary reimplantation (Figure 2). Coronary arteriogram could confirm the right coronary pseudo-aneurysm, figure 3. The repair of false aneurysm was successfully undertaken with revision of coronary-graft suture line. The current observation highlights the uselessness of systematic coronary graft transposition which is argued to prevent recurrent coronary pseudo-aneurysm. Beside its inherent thrombotic potential, coronary graft interposition requires a higher level of anticoagulation for this subset of patients who remain at risk of further aortic complications. Thereby avoidance of wrap-inclusion seems to be more determinant.
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Figure 1. X-ray 8 months postoperatively shows a widened mediastinal shape with prominent right superior outline (arrow).
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Figure 2. Top: Computed tomography reveals a huge mediastinal haematoma with leakage of contrast material. The curved-arrow indicates the previous aneurysmal sac used for inclusion; the vertical-arrow demonstrates the indirect left coronary reimplantation. Bottom: the leakage is localized on the area of right coronary implantation (arrow); the curved-arrow shows the indirect left coronary reimplantation.
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Figure 3. Coronary arteriogram confirms the coronary pseudo-aneurysm (arrow); the curved-arrow shows the prosthetic coronary graft.
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