Complete graft dehiscence 8 months after repair of acute type A aortic dissection

Abstract

Acute type A aortic dissection is a dreaded differential diagnosis of acute chest pain. Long-term outcome mainly depends on pre-existing comorbidities and post-operative complications. We present a patient with aortic graft dehiscence and subsequent severe aortic regurgitation due to fungal graft infection 8 months after repair of acute type A aortic dissection. Redo aortic surgery had to be delayed for 28 days due to intracerebral haemorrhage caused by septic embolism and clipping of a mycotic left middle cerebral artery aneurysm. Surgery revealed a circumferentially detached graft at the site of the proximal anastomosis thereby forming a massive pseudoaneurysm. The patient underwent successful aortic root replacement using a Freestyle porcine root bioprosthesis (25 mm), followed by re-anastomosis of the coronary arteries and partial replacement of the ascending aorta with a 28 mm Dacron graft. The patient was discharged on day 67 in stable cardiac condition with persistent neurological deficits. This case highlights the challenging management of patients with aortic graft infection and neurological dysfunction after redissection of the ascending aorta who require redo cardiac surgery.

Mycotic Aortic Aneurysms

“…Some groups have presented lower rates of recurrent infection and lower morbidity and mortality rates associated with rifampicin-soaked Dacron grafts compared to those with untreated grafts [34,45].…”

“…Mycotic saccular, fusiform, and pseudoaneurysms of the ascending and descending thoracic aorta have been described in the literature. Repair of these aneurysms may be performed with different techniques, including cryopreserved arterial homografts, prosthetic antibiotic-soaked grafts, visceral debranching and endovascular stent-graft repairs, bovine pericardium patch grafts, and Dacron grafts with biological tissue coverage [34,45,52].…”

“…Bacterial, viral, fungal, and protozoal infections have been described after cardiac transplantation, understanding that these patients under immunosuppressive medication are at risk of mycotic aneurysm formation [58]. In cases of ascending, arch, or descending thoracic mycotic aneurysms associated with severe mediastinitis, surgical techniques for aortic repair include cryopreserved arterial homografts, repair with deep or superficial femoral veins, coverage with the use of the greater omentum, creation of pedicled muscular flaps for arterial coverage, tissue debridement, and sternal re-closure [45,57,58].…”

“…The incidence of prosthetic aortic graft infection has been described in 0.5-2% of cases, including both early and delayed-onset complications [45]. All these prosthetic graft infections are associated with high morbidity and mortality rates.…”

Right Sided Heart Failure-An Unusual Presentation of Aortic Valve Dehiscence

“…The 30 day mortality for the surgery is as high as 27% and the 6 year survival rate only 13.5% [2]. Expeditious surgery may not be possible in setting of complications from septic embolization such as mycotic aneurysms and hemorrhagic strokes [8].…”