Aorto-Pericardial Filling Without Tamponade: An Unusual Late Bentall Complication

After Research Ethics Board approval, we present the case of a 61-yr-old woman who was transferred to our hospital 2 yr after a Bentall procedure and with a diagnosis of right ventricular (RV) infarction and severe RV dysfunction. She presented 10 days earlier at the referring center with progressive shortness of breath, severe weakness, nausea, and vomiting. A transthoracic echocardiogram was performed that demonstrated hypokinesis of the basal and inferior walls with RV dilation. Her serum Troponin I was elevated. The initial differential diagnosis included viral myocarditis and non-ST elevation myocardial infarction possibly because of right coronary artery (RCA) pathology. The patient subsequently developed cardiogenic shock, hepato-renal failure, and disseminated intravascular coagulation. She was tracheally intubated, given inotropes, and dialyzed. At this time she was transferred to our hospital for management and further cardiothoracic opinion. On arrival, a transesophageal echocardiogram (TEE) was performed. In the upper esophageal view at 0° using color flow Doppler, a high velocity jet was seen; it appeared to originate from the anterior aspect of the aortic graft and created a large anterior collection measuring approximately 6 × 8 cm (Fig. 1) (see Video 1, Supplemental Digital Content 1, showing upper esophageal, long-axis view of the ascending aortic prosthesis; a high velocity jet is seen to fill the pseudoaneurysm; https://links.lww.com/A1367). The right atrium (RA) and RV were both dilated and no significant RV compression was seen. In the transgastric view, there was diastolic septal flattening (see Video 2, Supplemental Digital Video 2, showing transgastric short-axis view of the left and right ventricles [RV]; The RV appears dilated with a flattened septum; https://links.lww.com/A1368) as a result of right-sided volume overload. There was also severe tricuspid regurgitation (Fig. 2). The patient was transferred to the operating room with a diagnosis of RCA button dehiscence and large anterior collection. Femoral-femoral bypass and cooling were instituted before chest opening. Intraoperative TEE (midesophageal RV outflow 24° scan angle) demonstrated blood flow between the collection and the RV outflow tract (RVOT) (Fig. 3) (see Video 3, Supplemental Digital Content, showing midesophageal 4-chamber view with scan angle of 24°; a communication is seen between the pericardium and the right ventricle [RV] in the region of the RV outflow tract [RVOT]; https://links.lww.com/A1369). The operative findings were complex and included large pseudoaneurysm formed by surgical adhesions, detachment of the proximal RCA graft from the synthetic aortic prosthesis, a leak at the distal graft anastomosis, a fistula between the pseudoaneurysm and the RVOT, and a second, previously unrecognized, fistula between the pseudoaneurysm and the RA. The following procedures were performed: primary repair of the distal aortic leak and dehisced RCA, debridement and over-sewing of the RA fistula, debridement and a pericardial patch to close the fistula to the RVOT. After a protracted postoperative course, the patient was discharged home on Day 31.Figure 1.: Upper esophageal, short-axis view of the ascending aorta (Ao). There is a high velocity jet (arrow) resulting from the dehiscence of the right coronary artery (RCA) anastomosis, which communicates with a large collection (*) anterior to the ascending aorta.Figure 2.: Midesophageal four-chamber view at 0° with rightward probe rotation. A pericardial fluid collection (*) with flow within on color flow Doppler is seen lateral to the right ventricle (RV). The right atrium (RA) is grossly enlarged. There is severe tricuspid regurgitation (TR).Figure 3.: Midesophageal four-chamber view with a scan angle of 24° showing a communication (arrow) between the pericardium (*) and the right ventricle (RV) near the right ventricular outflow tract (RVOT). The left ventricle (LV) and right atrium (RA) are also demonstrated.Bentall’s procedure is a surgical option for the treatment of ascending aortic aneurysm. The overall mortality for this procedure is <5% and approaches 1.5% in elective operations. Complications include thromboembolism, endocarditis, and pseudoaneurysm particularly at the coronary ostia and distal aortic suture lines. Modifications to the original procedure have occurred to reduce tension on the coronary anastamosis. Of particular interest is the Cabrol procedure that includes over-sewing the native aorta around the prosthesis and creating a shunt into the RA to drain anastomotic leakage from the periprosthetic space.1 This prevents the formation of a tense hematoma and pseudoaneurysm formation. The shunt would close spontaneously but there have been reports of persistent Cabrol shunts.2,3 To our knowledge, this is the first report of a patient surviving a significant periprosthetic pseudoaneurysm with detachment of the RCA and a distal aortic graft leak after a Bentall’s procedure without a Cabrol shunt. Sakano et al. reported a similar case after Bentall’s procedure with a Cabrol shunt in which the pseudoaneurysm created a fistula to the RA. The Cabrol shunt was found to be completely thrombosed.4 Hoffman et al.5 reported a similar case with a fistula from the ascending aorta entering the main pulmonary artery. Late coronary graft avulsion is an unusual complication after Bentall’s procedure. Intraoperative biopsies in our patient were sterile invoking the possibility of an inflammatory process. Preoperative TEE was able to outline the pathology in this case. TEE also proposed an anatomic mechanism for right-sided filling in the setting of a high-pressure pseudoaneurysm. Our patient’s unusual presentation of an aortic pseudoaneurysm without compression of the RV or RA suggests that the pressures in the pericardium, RV, and pseudoaneurysm were very similar. An inflammatory process likely resulted in a small dehiscence at the RCA button. The resulting jet of blood created both the pseudoaneurysm and fistula to the adjacent RVOT. It is likely that this leak increased until the RCA detached completely resulting in RV dysfunction. Fortuitously, a fistula allowed considerable return of blood to the right side of the circulation. Our images lead us to suspect that the fistula to the RVOT was the primary reentry point. This would explain the dilation of the RV and the resulting tricuspid regurgitation. A second fistula to the RA found by the surgeon had not been previously identified by TEE. The identification of a large pericardial collection in the presence of hemodynamic compromise would normally trigger a diagnosis of pericardial tamponade. Routine surgical management in this case would likely have resulted in an adverse outcome. Use of TEE identified the unusual features of RCA dehiscence, RA, and RV dilation requiring closer investigation and a cautious approach to the subsequent anesthetic and surgical management.

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