Valve-sparing root replacement (VSRR, the David procedure) is a valuable alternative to conventional aortic root replacement (with a composite graft), especially in patients whose aortic valve leaflets have not been altered.^1,2 Even in patients with congenital abnormalities like Marfan syndrome or bicuspid aortic valve, VSRR is accepted as an effective treatment.³ However, reintervention rates are higher than are those associated with composite graft implantation. In this report, we present the case of a patient who had undergone VSRR 2 years before his admission to our hospital with myocardial infarction and cardiogenic shock secondary to aortic pseudoaneurysm (APA) formation and left main coronary artery (LMCA) compression.

Case Report

A 67-year-old man with a 6-hour history of dyspnea was admitted to our emergency department. Two years before, he had received a diagnosis of ascending aortic aneurysm and chronic aortic dissection and had undergone aortic root replacement. His aortic root had been 32 mm in diameter, and his ascending aorta 60 mm. From his operative report, we learned that a remodeling-type David operation had been performed: the coronary artery buttons had been displaced 1 cm, and a 32-mm Dacron prosthetic graft had been used.

On physical examination, the patient had a blood pressure of 90/50 mmHg, a heart rate of 110 beats/min, and crackles in the bases of both lungs. His electrocardiogram revealed pathologic Q waves in leads V₁ through V₃. His echocardiogram showed hypokinesia of the mid and apical segments of the anteroseptal and anterior left ventricular (LV) wall. His cardiac biomarkers were highly compatible with myocardial infarction.

We performed emergency coronary angiography via the femoral artery. During selective cannulation of the LMCA, the left Judkins catheter entered a fistulous connection at the left sinus of Valsalva and thereby revealed a pseudoaneurysm (Fig. 1). The ostium of the LMCA was compressed beneath this structure, which resulted in severe arterial stenosis (Fig. 1). Flow was impaired distally in the left anterior descending and left circumflex coronary arteries. The right coronary artery was normal. We terminated the procedure and performed emergency computed tomography with 3-dimensional reconstruction; this showed an APA (2.2 × 1.1 cm in diameter) that originated adjacent to the ostium of the LMCA (Figs. 2–4).

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The patient was immediately taken to the operating room. Upon detaching the LMCA ostial button from its proximal edge, we saw an APA originating from this site and extending laterally above the LMCA. When the aortic valve leaflets were retracted, tiny nodular structures resembling vegetations were seen on the ventricular surface of the leaflets. The pressing nature of this operation did not permit time to rule out infective endocarditis; therefore, rather than attempt local reconstruction of the mouth of the APA, we excised the APA, the aortic valve, and the graft, and we implanted a composite aortic graft with a mechanical aortic valve. The blood cultures and a culture of the operative material did not yield any specific microorganism. However, the patient was given antibiotic therapy during his 10 days of hospitalization. Follow-up echocardiography 4 weeks after dismissal from the hospital revealed a properly functioning prosthetic aortic valve and normal LV systolic function.

Discussion

Aortic VSRR is an effective means of treating aortic root dilation in patients who do not have aortic valve defects. During a 12-year follow-up period, the reoperative and long-term survival rates have been reported as 94.3% ± 2.6% and 82.9% ± 3.7%, respectively.¹ Aortic insufficiency is the chief indication for reintervention. Aortic pseudoaneurysm formation is a rare and silent complication that might not be diagnosed until severe symptoms develop. Aortic pseudoaneurysms can occur after the David or the Bentall operation.⁴ From a group of 31 patients who underwent reoperation after composite graft implantation, Raanani and colleagues⁵ reported the cases of 2 patients with the indication of pseudoaneurysm formation. Mohammadi and coauthors⁶ reported 12 APA cases among 202 (5.9%) patients who underwent aortic root replacement for aortic dissection and 3 cases among 683 (0.4%) patients who underwent operation for other indications. In our patient, the initial diagnosis was chronic aortic dissection, which increases the risk of APA. The anatomic location and the presence or absence of fistulous connections to the surrounding tissues can result in widely different symptoms in patients with APA. To our knowledge, this is an exceedingly rare case of severe LMCA compression and cardiogenic shock secondary to an APA that originated from the coronary ostial button. Coronary angiography and computed tomography were used to diagnose this rare sequela. In summary, emergency surgery resulted in restoration of the coronary flow and in normalization of LV systolic function. A composite graft with a mechanical aortic valve was implanted.

Conclusion

Aortic pseudoaneurysm formation is a rare but severe sequela of David's operation, which can present as coronary artery compression, myocardial infarction, or both.