IMAGE
Heart, Lung and Circulation (2015) 24, e136–e138 1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2015.03.014
Computed Tomography in Prosthetic Aortic Graft Infections Jen-Li Looi, MBChB *, Ruvin Gabriel, MBChB Department of Cardiology, Middlemore Hospital, Auckland, New Zealand Received 5 March 2015; accepted 21 March 2015; online published-ahead-of-print 30 March 2015
Keywords
Computer tomography Echocardiogram Prosthetic aortic graft infections
Prosthetic aortic grafts infection is associated with considerable morbidity and mortality. Staphylococcus species are the most commonly implicated causative organisms. Computed tomography (CT) is the imaging modality of choice in the investigation of patients with suspected prosthetic aortic graft infection, particularly in the assessment of abscess and pseudo-aneurysms associated with aortic graft infections. We describe two cases in which CT provides incremental information about the complications associated with prosthetic aortic graft infection which is essential in guiding treatment and management. Case 1: 45 year-old man with previous Bentall’s graft with 25 mm St Jude valve conduit for bicuspid aortic valve and dilated aortic root presented with night sweats, weight loss, and rash. Transthoracic echocardiogram (Fig. 1A, video I) demonstrated a large pseudo-aneurysm anterior to the Bentall’s with free moving echogenic mass within likely consistent with vegetations. CT thoracic aorta (Fig. 1B-1D) showed a large complex pseudo-aneurysm anterior to the aortic root and the main pulmonary artery with fistula origin at the right coronary artery anastomosis. He subsequently underwent redo Bentall’s procedure with 23 mm ATS bileaflet
mechanical valve and 30 mm Gelweave valsalva graft. Surgery confirmed a large pseudo-aneurysm arising from the aortic root with vegetations in the cavity. Propionibacterium acnes was isolated and he was treated with six weeks of intravenous benzyl penicillin followed by oral penicillin for three months. Case 2: 19 year-old man with end-stage renal failure presented with an aortic root abscess (Fig. 2A) secondary to Methicillin-resistant Staphylococcus aureus bacteraemia with the presumed infection likely arising from right internal jugular tunnelled line for haemodialysis. He underwent an urgent homograft aortic root replacement in view of severe aortic incompetence (Fig. 2B) and complete heart block. Postoperative echocardiogram (Fig. 2C & 2D, videos II & III) showed a large paravalvular echo free space posteromedially and another anterolaterally consistent with pseudoaneurysm. CT thoracic aorta (2E & 2F) demonstrated two pseudo-aneurysms arising from the left ventricular outflow tract. Redo aortic root replacement was performed but complicated by significant bleeding from the root despite multiple suturing, topical measures and packing, and eventually he died.
*Corresponding author. Department of Cardiology, Middlemore Hospital, Private Bag 93311, Otahuhu, Auckland 1640, New Zealand. Tel.: +649 276 0061; fax: +649 2709746, Email: [email protected] © 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved.
Prosthetic aortic graft infection
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Figure 1 A. Parasternal long axis view on transthoracic echocardiogram demonstrated a large pseudo-aneurysm anterior to the Bentall’s (yellow arrow) with free moving echogenic mass (red arrow) within likely consistent with vegetations. B & C. CT thoracic aorta showed a large complex pseudo-aneurysm (arrows) anterior to the aortic root and the main pulmonary artery with fistula origin at the right coronary artery anastomosis (arrowheads). D. Volume rendered image of the CT thoracic aorta demonstrating a large pseudo-aneurysm (arrows) anterior to the aortic root and main pulmonary artery.
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Figure 2 A. There was thickening of the aortic root (arrows) noted on parasternal long axis view and parasternal short axis view of the aortic valve consistent with root abscess. B. There was severe aortic regurgitation noted on colour Doppler on transthoracic echocardiogram. C. Parasternal long axis view on transthoracic echocardiogram showed a large paravalvular echo free space (arrows) anterolaterally (arrows) consistent with pseudo-aneurysm. D. There was another large paravalvular echo free space (arrows) posteromedially noted on the parasternal short axis view at the aortic valve level. E & F. CT thoracic aorta demonstrated two pseudo-aneurysm (arrows) arising from the left ventricular outflow tract (arrowhead).
Conflict of interest
Appendix A. Supplementary data
None
Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.hlc. 2015.03.014.
Acknowledgements None
Heart, Lung and Circulation (2015) 24, e136–e138 1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2015.03.014
Computed Tomography in Prosthetic Aortic Graft Infections Jen-Li Looi, MBChB *, Ruvin Gabriel, MBChB Department of Cardiology, Middlemore Hospital, Auckland, New Zealand Received 5 March 2015; accepted 21 March 2015; online published-ahead-of-print 30 March 2015
Keywords
Computer tomography Echocardiogram Prosthetic aortic graft infections
Prosthetic aortic grafts infection is associated with considerable morbidity and mortality. Staphylococcus species are the most commonly implicated causative organisms. Computed tomography (CT) is the imaging modality of choice in the investigation of patients with suspected prosthetic aortic graft infection, particularly in the assessment of abscess and pseudo-aneurysms associated with aortic graft infections. We describe two cases in which CT provides incremental information about the complications associated with prosthetic aortic graft infection which is essential in guiding treatment and management. Case 1: 45 year-old man with previous Bentall’s graft with 25 mm St Jude valve conduit for bicuspid aortic valve and dilated aortic root presented with night sweats, weight loss, and rash. Transthoracic echocardiogram (Fig. 1A, video I) demonstrated a large pseudo-aneurysm anterior to the Bentall’s with free moving echogenic mass within likely consistent with vegetations. CT thoracic aorta (Fig. 1B-1D) showed a large complex pseudo-aneurysm anterior to the aortic root and the main pulmonary artery with fistula origin at the right coronary artery anastomosis. He subsequently underwent redo Bentall’s procedure with 23 mm ATS bileaflet
mechanical valve and 30 mm Gelweave valsalva graft. Surgery confirmed a large pseudo-aneurysm arising from the aortic root with vegetations in the cavity. Propionibacterium acnes was isolated and he was treated with six weeks of intravenous benzyl penicillin followed by oral penicillin for three months. Case 2: 19 year-old man with end-stage renal failure presented with an aortic root abscess (Fig. 2A) secondary to Methicillin-resistant Staphylococcus aureus bacteraemia with the presumed infection likely arising from right internal jugular tunnelled line for haemodialysis. He underwent an urgent homograft aortic root replacement in view of severe aortic incompetence (Fig. 2B) and complete heart block. Postoperative echocardiogram (Fig. 2C & 2D, videos II & III) showed a large paravalvular echo free space posteromedially and another anterolaterally consistent with pseudoaneurysm. CT thoracic aorta (2E & 2F) demonstrated two pseudo-aneurysms arising from the left ventricular outflow tract. Redo aortic root replacement was performed but complicated by significant bleeding from the root despite multiple suturing, topical measures and packing, and eventually he died.
*Corresponding author. Department of Cardiology, Middlemore Hospital, Private Bag 93311, Otahuhu, Auckland 1640, New Zealand. Tel.: +649 276 0061; fax: +649 2709746, Email: [email protected] © 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved.
Prosthetic aortic graft infection
e137
Figure 1 A. Parasternal long axis view on transthoracic echocardiogram demonstrated a large pseudo-aneurysm anterior to the Bentall’s (yellow arrow) with free moving echogenic mass (red arrow) within likely consistent with vegetations. B & C. CT thoracic aorta showed a large complex pseudo-aneurysm (arrows) anterior to the aortic root and the main pulmonary artery with fistula origin at the right coronary artery anastomosis (arrowheads). D. Volume rendered image of the CT thoracic aorta demonstrating a large pseudo-aneurysm (arrows) anterior to the aortic root and main pulmonary artery.
e138
J.-L. Looi, R. Gabriel
Figure 2 A. There was thickening of the aortic root (arrows) noted on parasternal long axis view and parasternal short axis view of the aortic valve consistent with root abscess. B. There was severe aortic regurgitation noted on colour Doppler on transthoracic echocardiogram. C. Parasternal long axis view on transthoracic echocardiogram showed a large paravalvular echo free space (arrows) anterolaterally (arrows) consistent with pseudo-aneurysm. D. There was another large paravalvular echo free space (arrows) posteromedially noted on the parasternal short axis view at the aortic valve level. E & F. CT thoracic aorta demonstrated two pseudo-aneurysm (arrows) arising from the left ventricular outflow tract (arrowhead).
Conflict of interest
Appendix A. Supplementary data
None
Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.hlc. 2015.03.014.
Acknowledgements None
