Abstract
A pseudoaneurysm with compression of the left main coronary artery causing significant ischaemia was successfully treated with a covered stent. We report this rare complication of cardiac surgery for infective endocarditis with a large root abscess. The patient developed a pseudoaneurysm arising from the body of the left main and causing compression of this vessel following his fourth redo aortic valve replacement for staphylococcal endocarditis. The endocarditis had been successfully managed and ongoing infection was excluded. The patient was then treated percutaneously with a covered stent that excluded the aneurysm and relieved the stenosis in the vessel.
1
Introduction
We report a rare complication of cardiac surgery for infective endocarditis (IE) with a root abscess. The patient developed a pseudoaneurysm arising from the body of the left main coronary artery causing compression of this vessel following his fourth redo aortic valve replacement (AVR) for staphylococcal endocarditis. The origin of the aneurysm was treated with a covered stent.
2
Case history
A 51-year-old indigenous male presented for follow-up of his fourth redo AVR. Other medical history included being hepatitis C positive. He was a smoker and a reformed intravenous drug user. In September 1989, he initially had staphylococcal IE of the aortic valve thought to be secondary to drug abuse with severe aortic regurgitation (AR) and underwent AVR with a bioprosthetic valve.
In January 1998, he again developed Aortic Valve endocarditis and a brain abscess and left ventricular septal abscess with severe AR and underwent a redo AVR with aortic root replacement utilizing a homograft valve. In October 2004, he was unfortunate enough to redevelop an aortic root infection with severe AR and underwent aortic root re-replacement, again with a homograft valve.
In February 2006, he contracted IE of the homograft with a large peri-aortic abscess and severe AR for which he underwent aortic root re-replacement.
In January 2008, he presented with NYHA Class 3 dyspnoea and lethargy. A transoesophageal echocardiogram showed multiple abscesses around the aortic root and severe AR, moderate mitral regurgitation and tricuspid regurgitation, and ejection fraction of 35–43%. He was re-operated on with aortic root replacement, mitral, and tricuspid valve repair. The aortic root abscess passed over the roof of the left atrium adjacent to the left main trunk, passing behind the main pulmonary artery to involve the base of the left atrial appendage. The abscess was widely debrided and the aortic root replaced with a new homograft. Significant bleeding at operation necessitated division of the main pulmonary artery in order to repair the roof of the left atrium and close the base of the left atrial appendage, re-anastomosing the main pulmonary artery following reasonable haemostasis. Post surgery, he was in intermittent third-degree heart block for 10 days but gradually regained sinus rhythm.
Follow-up echocardiogram performed 6 months post surgery identified a pseudoaneurysm of the left main coronary artery. The aneurysm was further delineated with multimodality imaging including cardiac magnetic resonance imaging (MRI) and computed tomography coronary angiography (CTCA). This demonstrated a large pseudoaneurysm arising from the mid body of the left main coronary artery, compressing the left main to a slit-like narrowing ( Fig. 1 A and B). His logistic EuroSCORE was 10.5%, but he was at higher risk of further surgery in view of multiple previous operations. He was referred for percutaneous intervention, a surgery considered very high risk. There was no evidence of infection, with C-reactive protein level within normal limits, negative blood cultures on multiple occasions, and no clinical evidence of active infection. While being evaluated, the patient became symptomatic with episodes of pulmonary oedema and chest pain associated with systolic left ventricular dysfunction presumed to be related to left main stem ischaemia. An angiogram showed a large proximal left main coronary artery pseudoaneurysm ( Fig. 2 A and B). There was a mid-vessel 70% stenosis of moderate length, related to the pseudoaneurysm compressing the left main artery. It was decided to treat the origin of the aneurysm with a covered stent. The procedure was done electively.
An intravascular ultrasound (IVUS) of the lesion was carried out ( Fig. 2 C). The size of the distal left main was 3.5 mm and proximally 4.0 mm. The origin of the pseudoaneurysm opening in the left main was identified. Left main was compressed at the mid segment. This left main, including the origin of the aneurysm, was stented with a 3.5×19-mm covered stent (Abbott Graftmaster, Abbott Vascular, Santa Clara, CA, USA). The vessel was postdilated. The stent was then post dilated with a 4.0×12-mm Quantum Maverick (Boston Scientific, Natick, MA, USA) noncompliant balloon at 20 atm. There was no residual stenosis postdilatation. Postprocedure angiogram showed a trivial leak. Postprocedure IVUS showed a well-expanded stent.
The patient was reviewed with a repeat angiogram in a month’s time ( Fig. 3 ). There was no evidence of residual blood flow into the pseudoaneurysm. At 1-year clinical and CTCA follow-up, the patients were well with no evidence of pseudoaneurysm.
