Double pseudoaneurysms of the aortic bulbus after aortic valve replacement surgery

A pseudoaneurysm of the ascending aorta (PAA) represents a rare, life-threatening complication in cardiac surgery [1]. The anatomical localization and expansion lead to compression or an erosive effect on the structures of the mediastinum produces heterogeneous symptoms as well as the pulsating mass, dysphagia, hoarseness, stridor, or angina due to obstruction of the coronary blood vessel or graft. The weakness of the wall leads to an increased probability of spontaneous rupture which could result in mediastinal hemorrhage, acute cardiac tamponade, hypovolemic shock and death. Surgical treatment is mandatory because of the high risk of a fatal outcome [2].
We present a patient with double pseudoaneurysms of the ascending aorta with the origin from the right sinus which completely occluded the right coronary artery and produced ischemic heart symptoms.
A 61-year old woman was admitted with an eight-month history of fatigue, a sense of palpitation, irritating dry cough and hoarse voice. The patient’s past medical history showed that aortic valve replacement was performed 4 years ago when the mechanical prosthesis was implanted.
Transthoracic echocardiography revealed a newly formed 4-cm-wide cystic formation as well as a smaller round cavity behind it. The origin of the cyst was from the right and non-coronary sinus of Valsalva. Color Doppler showed communication between the aorta and the larger cavity during systole. Transesophageal echocardiography (TEE) revealed a cystic formation arising from the aortic root, extending in front of the right atrium and ventricle. It was 6.8 × 4.5 cm in diameter, divided into two cavities, a larger front and a smaller rear with mural thrombosis.
Contrast multislice CT (MSCT) examination revealed two separated aneurysmal formations with large mural thrombosis along the right edge of the aortic bulbus, as well as anteriorly (Figures 1 A, B). The larger formation was found in the projection of the root of the right coronary artery, and also the smaller pseudoaneurysm along its origin (Figure 2 A).
Aortography revealed two pseudoaneurysmal formations in the right part of the aortic bulbus which completely occluded the origin of the right coronary artery, which could be visualized only due to retrograde flow from left coronary artery (Figure 2 B).
The patient underwent surgery immediately after the diagnostic procedures were done. Cardiopulmonary bypass (CPB) was instituted by means of right...


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