Mycotic ascending aortic pseudoaneurysms are extremely uncommon and multiple aneurysms in a single patient have rarely been reported in the literature. Early diagnosis of this condition is important given the high mortality associated with spontaneous rupture. Definitive treatment is surgical repair of the aorta.
A 58 year old Haitian male presented to an outside facility with chest pain and fever. His past medical history included hypertension
, coronary artery disease
(diagnosed after a medically managed myocardial infarction), ischemic stroke
, and tobacco abuse. He had suffered a motor vehicle collision 27 years prior resulting in a mandibular fracture treated with maxillomandibular fixation. The wires were never removed, and he fed himself through a gap in his teeth.
On initial presentation, his electrocardiogram
revealed greater than 2 mm ST segment elevation in the inferior leads and leads V1-4. Emergent cardiac catheterization revealed a 90% left anterior descending artery (LAD) lesion, and a bare metal stent was successfully placed. A ventriculogram revealed normal LV function and no mitral regurgitation. Significant calcification of the ascending aorta was noted (Figure 1). Laboratory results were remarkable for a leukocytosis
. Blood cultures were significant for methicillin-resistant staphylococcus aureus (MRSA) bacteremia. A subsequent computed tomography (CT) scan of chest, abdomen and pelvis did not reveal a source of infection. An echocardiogram was performed and reported as normal. The patient was treated for uncomplicated MRSA bacteremia with broad-spectrum intravenous antibiotics for 16 days and discharged home with resolution of his symptoms.
Approximately six weeks after discharge, the patient had recurrence of his chest pain and returned to the local emergency department. The electrocardiogram revealed significant 2 mm ST segment elevation in leads V2-4 and repeat emergent coronary angiography
revealed a patent LAD stent without other coronary artery disease. Significant laboratory data included a leukocytosis with 75% polymorphonuclear neutrophils, an elevated erythrocyte sediment rate and C-reactive protein, and an elevated troponin and CK-MB. Blood cultures were negative. An echocardiogram was interpreted as abnormal with new atrial septal thickening, a large circumferential pericardial effusion, and the suggestion of a mass in both the right atrium and left atrium. The patient was then transferred to our facility for further evaluation of the cardiac mass.
On arrival, his physical exam was significant for a blood pressure of 109/57 mm Hg without a paradox, heart rate of 77 beats/min and regular and a temperature of 36.3 degrees C. There was no evidence of right heart pressure elevation or loss of pulses. A chest wall echocardiogram revealed an echo-lucent mass in the area of the transverse pericardial sinus with extension into anterior pericardium, left atrium and right atrium suggesting a cardiac tumor (Figures 2 and 3). A magnetic resonance imaging was not feasible due to the jaw wires. A CT scan was obtained that showed multiple aortic pseudoaneurysms involving the ascending aorta
, inferior aspect of the aortic arch and the right subclavian artery. The masses seen on the chest wall echocardiogram were related to a massive pericardial hematoma seen on CT images (Figures 4 and 5).
A workup was undertaken to understand the etiology of the multiple aortic pseudoaneurysms. There was little evidence for vasculitis with a negative rheumatologic work up including rheumatoid factor, Anti ds DNA, Anti smooth muscle Ab and ANA. HIV, syphilis and tuberculosis
were all ruled out. Repeat blood cultures were negative. The normal appearance of the ascending aorta at the time of cardiac catheterization suggests the staphylococcal bacteremia may have been causal, resulting in multiple mycotic aneurysmal formations with rupture into the pericardium. Remarkably, the aortic rupture did not result in acute tamponade and death.
Cardiothoracic surgery was consulted for repair of the pseudoaneurysms. Given the involvement of the ascending aorta, inferior aspect of the aortic arch and the right subclavian artery, repair would require ascending aorta and total arch replacement. It was felt his operative risk would be unacceptably high due to associated porcelain aorta, need for tracheostomy given his permanently wired jaw as well as severe malnutrition. The options were discussed with the patient and his caregivers, and he was eventually discharged to home hospice. Approximately four weeks after discharge from our facility, the patient developed massive hemoptysis
and died suddenly in hospice care.