Young Patient's Challenge: Infective Endocarditis, Redo Bentall, Left Main Stenting, and Pseudoaneurysm Development

An eighteen-year-old young man was referred from another heart center with the finding of an aortic pseudoaneurysm following a redo Bentall procedure. The patient’s medical record included two previous cardiac surgeries. In August 2022, he underwent a Bentall procedure due to severe stenosis of the bicuspid aortic valve. Two months later, he underwent a redo Bentall with the exchange of previous aortic prosthesis and prosthetic valve due to Infective endocarditis and leadless pacemaker insertion for a persistent complete heart block after surgery. The technique that was employed in a previous operation was the button technique using a Valsalva conduit. 

In June 2023, the patient suffered myocardial infarction and a percutaneous stenting of left main coronary artery was performed successfully. A follow up computed tomography months later revealed a large pseudoaneurysm with a suspected internal leak from the left coronary cusp measuring 51 × 61 × 61 mm. At this point, the patient presented with a history of episodes of spontaneous bleeding through a small skin fistula at the sternotomy scar. Given the CT scan findings and clinical picture the decision was made to perform surgery. It is worth mentioning that the patient had an occluded right coronary from before but remained asymptomatic at presentation. 

To begin, the patient was placed on cardiopulmonary bypass through femorofemoral cannulation. The temperature was lowered to 18 degrees Celsius anticipating the need for deep hypothermic circulatory arrest. As the temperature was lowered, the sternum was opened and the team was surprised to find a sternal gaping which had what they presumed to be a connection to the pseudoaneurysm. The pseudoaneurysm was visualized and entered after securing circulatory arrest. It was large with multiple clots within. The ascending aortic graft was clamped and circulation was resumed. 

After clearing up the area, temporary unclamping of the aortic graft to identify the leak revealed a defect at the left main coronary anastomosis site and the graft with the annulus anastomosis site. The cross clamp was reapplied and cardioplegia was given. While the later defects were closed by sutures, the left main artery anastomosis defect was closed using bovine pericardium due to the presence of fibrosis over the stent. It was noted that the graft was rather long and kicked posteriorly, so it was transected completely and shortened. An attempt of endarterectomy of the right coronary artery was deemed unsuccessful, but as the patient was asymptomatic from that point of view it was decided not to pursue it further and the aortic graft was reattached. Once the leak was tested and sealed successfully, the patient was rewarmed and weaned off the cardiopulmonary bypass. 

The postoperative course was unremarkable. The patient was discharged home on the seventh day after surgery with negative results of blood and wound cultures.

References

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