Presentation
Mild stabbing chest pain for 4 weeks. History of aortic valve replacement for bicuspid aortic valve 10 years ago. There is also a history of mild ascending aortic dilatation on echocardiogram.
Patient Data
Cardiomegaly. Dilated ascending aorta. Status post sternotomy and aortic valve replacement. The lungs are clear.
Aneurysmal dilatation of the ascending aorta. Dissection of the ascending aorta extending to involve the proximal portion of the aortic arch with sparing of the coronary arteries, branches of the aortic arch and descending thoracic aorta (type A by Stanford classification). Status post sternotomy and aortic valve replacement. Incidental finding of the common origin of the brachiocephalic artery and the left common carotid artery (bovine arch).
Evidence of previous surgeries (aortic valve replacement and repair of aneurysm & dissection of the ascending aorta) are noted. A sizable fluid collection (likey a liquefied hematoma or seroma) measuring ~ 7 x 9 cm, exerting mass effect over the SVC, main pulmonary trunk & the right pulmonary artery, is seen around the ascending aorta. A focal area of high attenuation is seen within this collection close to the aortic root, in arterial & venous phases of the scan, which is likely an endoleak. Segmental consolidation/collapse is seen in the basal segments of the right lower lung lobe with elevated right copula of the diaphragm.
No abnormal radiotracer accumulation is seen in the imaged body either on early or on delayed phase imaging. Normal distribution of the radiotracer is noted in the liver, spleen, and bone marrow.
Case Discussion
Aneurysm and dissection of the ascending aorta were initially treated with replacement of the ascending aorta and repair of the dissection with Dacron graft (30 mm) in another cardiac center.
4 months later the patient presented with fever, shortness of breath, and diarrhea. Septic workup including blood culture was negative. Transthoracic echocardiography (TTE) did not show any vegetation, thrombus, or prosthetic valve dysfunction; however, dehiscence was found between the proximal end of the graft and the native aortic root tissue at the sino-tubular junction (STJ) anteriorly on transesophageal echocardiography (TEE) which was compatible with CT scan findings of an endoleak (type 1a). The patient was initially managed conservatively; however, follow-up echocardiograms and CT chest showed persistent peri-aortic fluid collection, an increase in the size of the endoleak, and development of aortic root aneurysm measuring 5 cm. 2 months later, finally, he underwent a Bentall procedure.
Currently, the patient is doing fine and is under regular follow-up with cardiology.
Aneurysm and dissection of the ascending aorta, in this case, were likely complications, related to the patient's history of the bicuspid aortic valve.