Discussion
Herein, we present a complicated case of an aortic cannulation site
pseudoaneurysm that occurred after DSWI following an AVR. The original
sternal infection was unlikely treated sufficiently and was most likely
the cause of the late development of pseudoaneurysm. Ultimately, he had
a challenging diagnosis and anatomy making emergent repair challenging.
The surgical repair of aortic pseudoaneurysms are variable and largely
patient dependent4–6. In cases with a small defect
and no sign of infection, a simple graft, composite replacement, patch,
or primary closure with a simple suture can be
considered4,7. In the presence of active infection,
aggressive debridement of the pseudoaneurysm including any grossly
infected aorta with closure and repair using allograft, bovine or
autologous pericardial patches4. Our patient presented
with a fungal mediastinal infection. Candida has found to be
particularly associated with significantly worse outcomes, with twice as
high mortality than bacterial causes of DSWI8. It is
likely that Candida mediastinal infection would require more
aggressive debridement and replacement of the aorta. In a more elective
setting, more complete aortic resection and replacement with homograft
or rifampin-soaked graft, may be more resistant to rebleed and/ or
reinfection.
When considering approach to re-sternotomy in these patients, femoral
artery cannulation, left ventricular venting, hypothermia, and
circulatory arrest are typically required3,7,9,10. In
a non-emergent setting, deeper cooling, the use of CO2 on the field, and
the ability to place an aortic root vent with sufficient exposure of the
aorta all may have been beneficial in preventing air
embolism11.
In summary, vigilance following DSWI should be maintained for several
months postoperatively. Recurrent infection should warrant urgent
imaging and a thoughtful approach when feasible. Multidisciplinary
approaches should be considered when feasible for optimal chances of
survival.
Conflicts of
Interest/Disclosures:
Ailawadi is a consultant for Medtronic, Admedus, Gore, Edwards, Abbott,
and Atricure (all <5K). The other authors have no disclosures.