Double Pseudoaneurysms of the Aortic Bulbus
after Aortic Valve Replacement Surgery
Krasic Stasa1* and Zivkovic Igor2
1Department of Cardiology, Mother and Child Health Care Institute of Serbia “Dr.Vukan Cupic”, Serbia
2Cardiovascular Institute, Serbia
Submission: April 08, 2019; Published: April 24, 2019
*Corresponding author: Krasic Stasa, Department of Cardiology, Mother and Child Health Care Institute of Serbia “Dr Vukan Cupic”, R. Dakica St. 6-8, 11070 Belgrade, Serbia
How to cite this article:Krasic S, Zivkovic I. Double Pseudoaneurysms of the Aortic Bulbus after Aortic Valve Replacement Surgery. J Cardiol & Cardiovasc Ther.
2019; 13(5): 555874. DOI: 10.19080/JOCCT.2019.13.555874
Pseudoaneurysm of the ascending aorta is a rare and very dangerous complications after cardiac procedures with heterogeneous clinical presentation.
We presented a patient with double pseudoaneurysms of the ascending aorta with origin from the right sinus which completely occluded right coronary artery and produced ischemic heart symptoms. The patient underwent to the surgery and the postoperative recovery was uneventful.
To the best of our knowledge, this is the first reported case of double pseudoaneurysms arising from the right edge of the aortic bulbus.
EA pseudoaneurysm of the ascending aorta represents a rare, life-threatening complication of cardiac surgical interventions .
The symptomatology of pseudoaneurysm of ascending aorta (PAA) is clinically heterogeneous. The anatomical localization of expansion which leads to compression or erosive effect on the structures of the mediastinum induces a corresponding clinical picture, which becomes even more versatile if there are two PAA. Contrast computer tomography (CT) scanning, magnetic resonance imaging, and echocardiography are diagnostic methods of PAA, with high sensitivity and specificity. Surgical treatment is mandatory because high risk of death exist .
We presented a patient with double pseudoaneurysms of the ascending aorta with origin from the right sinus which completely occluded right coronary artery and produced ischemic heart symptoms.
A 61-year old female was admitted with eight months history of fatigue, a sense of heart palpitation, irritating dry cough and hoarse voice. Тhe patient was operate four years ago, when stenotic aortic valve was replaced with mechanical prosthesis.
Transthoracic echocardiography revealed 4-cm-wide cystic formation as well as a smaller round cavity behind it. The origin of cyst was from the right and non-coronary sinus of Valsava. Color Doppler showed communication between the aorta and the larger cavity during systole.
Transesophageal echocardiography (TEE) found a cystic formation in the front and right part in relation to the root of the aorta, in front of the right atrium and chamber, 6.8 cm in diameter in the superior-inferior direction, and 4.5 cm in the mediolateral direction, divided into two cavities, a larger front and a smaller rear. Mural thrombosis was noted in the cavities. Also, a communication between the pseudoaneurysm and the aorta was clearly noted at the spot between the right and the non-coronary sinus of Valsava.
Contrast multislice CT (MSCT) examination discovered two separated aneurysmal formations with large mural thrombosis along the right edge of the aortic bulbus, as well as anteriorly (Figure 1). A larger formation was found in the projection of the root of the right coronary artery, and also a smaller pseudoaneurysm along its origin (Figure 2 & 3).
Cardiac categorization revealed two pseudoaneurysmal
formations in the right part of the aortic bulbus which completely
occlude the origin of the right coronary artery, which could
visualised only due to retrograde flow from left coronary artery
The patient was operated in deep hypothermia, without
the occurrence of intraoperative complications. There were no
complications during the postoperative period. The postoperative
recovery was uneventful.
The available medical literature reports an incidence of less
than 0.5 %, with high mortality rate (29 - 46 %) [2,3]. Previous
cardiac surgery procedure increases incidence rate more than 13%
. The etiology of PAA is multifactorial. The infection, connective
tissue disease, chronic hypertension, aortic calcification or trauma
increase the risk for creating false aneurysm. The most common
surgical cause of PAA are aortic injury on the area of cannulation
and cross – clamp, cardiologic needle place and on the suture
lines . The main pathophysiological mechanism represents the
delamination of the aortic wall, and created false lumen confined
only by fragile tunica adventitia . Weakness of wall leads to
an increased probability of spontaneous rupture which could
result in mediastinal haemorrhage, acute cardiac tamponade,
hypovolemic shock and death. The mechanisms of the appearance
of pseudoaneurysms have not been completely clarified. Dhadval
et al.  suggested two theories while uncovering the causes of
postoperative PA . According to the first theory, postoperative
bleeding through the thoracic drain, which was not taken care
of during the surgery, increases the risk of the appearance
of aneurysms. According to the second one, sternal infection
contributes to their appearance. In the case of our patient, none of
the mentioned factors was present.
The most common clinical signs and symptoms of ascending
aorta pseudoaneurysm are the pulsating mass, dysphagia,
hoarseness, stridor, or angina due to obstruction of the coronary
blood vessel or graft . The occurrence of myocardial infarction
caused by complete occlusion of the same is also possible.
Asymptomatic PAA was described in a few patients. The most
common were those who suffer from inflammatory diseases
(Behcet’s disease), or those with congenital disorders (Marfan
syndrome) . The available literature cites the example of PAA,
which induced occlusion of the right coronary artery ostium, by
inducing the same clinical picture as in the shown patient . The
occurrence of hemoptysis and hematemesis as a result of aorto -
bronchial and aorto - esophageal fistula is also described .
The diagnosis is set using TEE, contrast CT and nuclear
magnetic resonance (NMR) imaging, cardiac categorization, and
recently, contrast MSCT. Because of the possibility of visualization
of perivalvular PA, NMR is considered superior to CT and TEE, but
NMR is unacceptable for patients with artificial valves as well as
those with a pace maker . TEE and CT are used only in the
evaluation of the defect on the front wall of the ascending aorta
. However, TEE may be falsely negative in tests on the front
wall of the ascendant aorta in patients with aortic calcification, or
those with artificial heart valves, due to the creation of acoustic
shadows [10,11]. Ugolini et al.  states as the latest and most
successful diagnostic method for the assessment of the anatomic
details of false aneurysm the electron -beat computerized
tomography (EBCT), especially in patients with artificial aortic
valve and small PAA (5mm). EBCT can also be a way to see the
spread of PAA, as well as their relationship with the coronary
arteries and surrounding mediastinal structures .
Cardiac catheterization and angiography use to be the gold
standard in the diagnosis of pseudoaneurysm but is no longer
required due to the existence of modern non-invasive methods. It
is, however, still necessary if the symptomatology is dominated by
anginous ailments such as was the case with our patient in whom one of the two pseudoaneurysm completely occluded the origin
of the right coronary artery [7,8]. Until about 10 years ago, due to
the lack of adequate grafts in length, flexibility and curvature, the
surgical treatment was the only way for the disposal of ascending
aorta pseudoaneurysm. This method of treatment carried
certain risks. The reopening of the chest carries the risk of fatal
hemorrhage or air embolism . This risk increases during the
intervention of duplicate false aneurysm, as in our case. For this
reason, it is necessary to carefully plan the surgical procedure and
the protection of brain . On the other hand, Roselli et al. 
and Preveza et al.  preformed thoracic endovascular aortic
procedures (TEVAR) in patients with PAA, and they concluded
that endovascular technology can facilitate their treatment,
especially in high-risk individuals [14,15]. Consequently, now a
day endovascular procedure is limited to patients who have very
high intraoperative risk .
The specificity of the case of our patient is the existence of a
double pseudoaneurysm, which in itself is a rarity, but also the
fact that one of the two pseudoaneurisms led to occlusion of the
origin of the right coronary artery with the symptoms of unstable
angina pectoris. The available methods for our country, TTE, TEE,
CT and angiography as well as the selective coronary angiography
were used for diagnostics, and the treatment was surgery with