A Case of Mycotic Aneurysm of the Ascending Aorta at the Suture Line Early Post Orthotopic Heart Transplantation

Abstract

We report a 44 year old man who presented with a rapidly expanding mycotic aneurysm of the ascending aorta post orthotopic heart transplant for end stage dilated cardiomyopathy (Figure-1). Prior to transplant, he was bridged with HeartWare left ventricular assist device, and temporary extracorporeal right ventricular assist device (tempRVAD). The site of tempRVAD outflow graft was infected by multi resistant pseudomonas aeruginosa, treated with prolonged course of aminoglycosides with complete wound healing. At 6 weeks after transplantation, the patient presented with increasing malaise and pyrexia. Serial blood cultures revealed gram negative bacteraemia with multi resistant pseudomonas aeruginosa. A transoesophageal echocardiography showed no evidence of intra-cardiac endocarditis. CT chest and abdomen with contrast revealed 2 small ascending aortic aneurysms, presumably mycotic, at the level of aortic anastomosis suture line. PET scan showed increased FDG uptake in the ascending aorta consistent with an infective process. The size of aneurysm grew rapidly in serial weekly CT, despite of optimal antibiotic and blood pressure management. The patient subsequently underwent surgery 3 weeks after presentation, during which the aneurysm was successfully resected with replacement of ascending aorta with allograft. This case highlights the rare but significant occurrence of suture line aortitis with myocotic aneurysm presenting as bacteraemia during post-transplant period. A high index of clinical suspicions guiding appropriate imaging modalities is crucial in confirming the diagnosis. Once diagnosed, an early aggressive surgical approach is often indicated. Figure-1