997 Ascending Aorta Pseudoaneurysm 40 Years Following Surgical Atrial Septal Defect Repair

Abstract

Abstract Background Ascending aorta pseudoaneurysm is a rare postoperative complication of cardiac surgery. It is often attributed to infection and dehiscence at sites of aortotomy, cannulation, cross-clamp placement, and proximal coronary anastomoses. Mortality risk is 29-46% and this requires prompt surgical intervention. Case summary A 48-year-old woman who underwent atrial septal defect repair at 8 years of age, presented with chest pain radiating to the right shoulder and dyspnoea. Cardiac-gated CT angiography demonstrated a 21mm pseudoaneurysm arising anteriorly from the proximal ascending aorta, 6mm above the right coronary artery ostium, likely the site of previous cardioplegia cannula. There was active blood flow from the aorta into the pseudoaneurysm sac. It was heavily calcified, apart from a thinned irregular wall inferiorly, from which rupture was imminent. She underwent emergency surgery. Using femoro-femoral cardiopulmonary bypass, the chest was safely re-entered. Under mild hypothermia and distal ascending aorta cross-clamping, the pseudoaneurysm was resected and aorta repaired using a Gelweave patch. The patient recovered uneventfully and was discharged home after one week. Discussion Accurate imaging, primarily via cardiac-gated CT angiography, is crucial for diagnosis and surgical planning in patients presenting with aortic pseudoaneurysm, particularly those close to the aortic valve and coronary arteries. Operative strategy, including need for deep hypothermic circulatory arrest and/or graft replacement of aorta, depends on pseudoaneurysm anatomy. It is recommended that preventative measures are taken during the primary operation, inserting the cardioplegia cannula tip through full-thickness purse-strings and/or addition of separate oversewing sutures after decannulation. Alternative techniques of pseudoaneurysm repair are also discussed.