INTRODUCTION: A pseudoaneurysm of the aorta after cardiac transplantation is relatively rare but potentially life threatening complication in immunosuppressed cardiac recipients. Herein, we report a rare case of a pseudoaneurysm related to the outflow graft anastomosis site of the left ventricular assist device (LVAD) to the descending thoracic aorta.
CASE PRESENTATION: This is a 59-year-old male with past medical history of congestive heart failure, coronary artery disease status post coronary artery bypass grafting and mitral valve repair, renal insufficiency and pulmonary hypertension. He admitted to Thomas Jefferson University Hospital for severe heart failure recalcitrant to 2 inotropes. The Jarvik 2000 Flowmaker (Jarvik Heart, Inc) implantation was performed in December 2009. The outflow graft of the LVAD was anastomosed to the descending thoracic aorta with the aid of side-clamping using a 4-0 Prolene running suture. His postoperative course was unremarkable and he discharged from the hospital on postoperative day 7. In June 2010, after 6 months support with the LVAD, OHT was performed via redo-sternotomy. The outflow graft of the LVAD was densely adhered to the surrounding left lung, therefore the previous left thoracotomy had to be reentered. The outflow graft was divided with vascular staple and overswen with a 3-0 Prolene suture. The patient required an extended intensive care unit stay due to ventilator dependent respiratory failure. In July 2010, 5 week after the heart transplant, the patient experienced severe infection in which multiple culture from sputum, pleural fluids, urine and blood was positive for Pseudomonas aeruginosa, and furthermore, the patients developed necrotizing fasciitis of bilateral lower extremities required multiple course of fasciotomies and skin grafting caused by the same organism. In November 2010, the patient had an episode of hemoptysis at rehab facility. The further evaluation with bronchoscope revealed blood clot in his left lower lobe and computed tomography (CT) scan of the chest showed a pseudoaneurysm of the descending thoracic aorta at the anastomosis site of the outflow graft of the LVAD. He underwent endovascular stent graft placement urgently on the following day. However, his hemoptysis persisted and which required open repair of descending thoracic aorta using two aortic allograft. The culture of the pseudoaneurysm wall and the outflow graft material collected in the operating room were positive for Pseudomonas aeruginosa. The patient was treated with amikacin for 3 weeks and followed by tigacycline for additional 2 weeks based on the results of the culture. At 5 months follow-up, the patient is doing well with no signs of recurrence.
DISCUSSION: To the best of our knowledge, this is the first described case of a pseudoaneurysm of the descending thoracic aorta related to the outflow graft anastomosis site of the LVAD. Pseudoaneurysms of the great vessel in cardiac transplantation recipients had been reported, although most of these cases are suture lines or cannulation sites of the ascending aorta. In our experience, we have 5 consequence patients who had successfully bridged to transplantation after Jarvik 2000 LVAD implantation with its outflow graft anastomosed to the descending thoracic aorta and the presented case was the only case that experienced the pseudoaneurysm at the site of outflow anastomosis. Cohn et al. published their experience of 18 patients with Jarvik 2000 implantation followed by OHT. In their series, no patients had complication related to the remnant of the outflow graft or anastomosis site on the descending thoracic aorta. During follow-up in their patients, no evidence of infections or graft remnant related complication was noted. On the contrary, our patient suffered from systemic bacteremia of Pseudomonas aeruginosa and local evidence of Pseudomonas infection in the pleural cavity, blood stream, and outflow graft itself, which most likely contributed to the development of the pseudoaneurysm in this patient. Hemoptysis was an early and significant sign in our patient and enabled us to further investigate to diagnose this rare complication.
CONCLUSIONS: We reported a rare case of pseudoaneurysm of the descending thoracic aorta at the anastomosis site of LVAD outflow graft presented with the symptom of hemoptysis. The evidence of systemic and local infection and the immunosuppression of the cardiac transplantation recipient were thought to contribute the development of the pseudoaneurysm. Although pseudoaneurysm of the graft anastomosis site is rare, this complication should be treated in appropriate timing and strategy to avoid possibly lethal consequences after cardiac transplantation.
Reference #1 Cohn WE, Fikfak V, Gregoric ID, Frazier OH. Retention of left ventricular assist device outflow grafts after transplantation. J Heart Lung Transplant. 2008 Aug;27(8):865-8.
DISCLOSURE: The following authors have nothing to disclose: Kentaro Yamane, Hitoshi Hirose, Linda Bogar, Nicholas Cavarocchi, Atul Rao, Joshua Eisenberg, Scott Cowan, Nathaniel Evans
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