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.