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Thorax (1966), 21, 236.
Aneurysm of the ascending aorta presenting withpulmonary
stenosis
M. H. YACOUB, M. V. BRAIMBRIDGE,1 AND R. G. GOLD
From the Brornpton Hospital, London S.W.3
The symptoms and signs of aneurysms of thethoracic aorta are due
mainly to compression ofsurrounding mediastinal structures and
depend onthe size and location of the aneurysm. Compres-sion of the
trachea, bronchi, oesophagus, recurrentlaryngeal nerve, bone, and
superior vena cava iscommon, but pressure on the pulmonary artery
hasnot been described in spite of its intimate relationto the
ascending aorta.The object of this paper is to describe a case
presenting in this way and to discuss the particularsurgical
problems involved in the excision of suchan aneurysm.
CASE REPORT
E. D., a man aged 52 years, was admitted to theBrompton Hospital
in December 1963. He had ahistory of healed bilateral pulmonary
tuberculosis,and he suffered from recurrent attacks of
haemoptysisand bronchial infection. In January 1957 he had
beenadmitted to hospital in acute cardiac failure due tocoronary
thrombosis. Since then he had beenmoderately dyspnoeic.On
examination he was a heavily built man. The
pulse was in sinus rhythm, the blood pressure 120/80 mm. Hg, and
the jugular venous pressure wasnormal. An abnormal systolic impulse
was palpablein the second left intercostal space at the left
sternaledge. There was a moderately loud, harsh, inspira-tory
pulmonary ejection murmur, and the pulmonarycomponent of the second
sound was delayed andreduced in intensity but moved on respiration.
Bi-lateral basal crepitations were heard in the lungs,and the liver
was palpable one finger's breadthbelow the costal margin.The
electrocardiogram showed sinus rhythm with a
normal PR interval. The mean frontal QRS vectorwas -40°, and
there was right bundle-branch blockwith a terminal R' deflection in
V1 of 13 mm. Thesechanges were interpreted as indicating ischaemic
heartdisease.
'Preseat address: Cardiac Surgical Unit, St. Thomas's
Hospital,London S.E.1
The chest radiograph (Fig. 1) showed old bilateralapical
tuberculosis, and both lungs were emphyse-matous. The emphysema was
most marked in the leftupper lobe with bullae present. A
hemispherical mass,9 by 6 cm., lay to the left and in front of the
ascend-ing aorta. Its border was slightly irregular. andshowed
flecks of linear calcification laterally andsuperiorly. The heart
size was within normal limits.At right heart catheterization
difficulty was experi-
enced in passing the catheter into the pulmonaryartery. The
right ventricular systolic pressure was44 mm. Hg and the pulmonary
artery systolic pres-sure was 18 mm. Hg. the systolic gradient
being 24mm. Hg, with a single change in pressure fromarterialto
ventricular configuration in the vicinity of thepulmonary valve.
The angiogram (Fig. 2) showedcompression and distortion of the
right ventricularoutflow tract, pulmonary valve, and main
pulmonaryartery by a mass lying above and in front of them.The
aortic valve and lower part of the ascending aortawere normal. A
saccular aneurysm, measuring 8 by5-5 cm., arose from the upper part
of the ascendingaorta and contained clot. The neck of the sac was2
5 cm. in diameter. The Wassermann, Price's preci-pitin reaction,
Treponema pallidum immobilization,Reiter protein complement
fixation test, cardiolipinWassermann, and fluorescent treponemal
antibodytests were all negative.
Repair of the aneurysm was performed on 14 May1964 with the aid
of profound hypothermia by theDrew technique, using a bilateral
transverse incisionalong the lower border of the third rib dividing
thesternum. The circulation was arrested for 35 minutesat a
temperature of 12° C. The aneurysmal sac wasopened and the neck was
seen to be 2 5 cm. in dia-meter, with strong fibrous margins.
Direct suture ofthe defect in the aortic wall was performed
withinterrupted mattress sutures and reinforced with acontinuous
running stitch and a pericardial flap. Two-thirds of the sac was
removed and the remainder wasobliterated by sutures. During
rewarming of thepatient there was no bleeding from the suture
line.The emphysematous bullae in the left upper lobe
were obliterated by multiple catgut ligatures, a tech-nique that
avoided the air leak which is inevitablewith excision and suture.
The chest was closed and atracheostomy was performed.
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Aneurysm of the ascending aorta presenting with pulmonary
stenosis23
FIG. 1. Pre-operative radiograPh showsaii ascending aortic
aneurysm and healedapical tuberculosis and emphysema.
Artificial ventilation was required for three weeks,following
which the patient made an uneventfulrecovery. The pulmonary
ejection murmur dis-appeared immediately after operation.
Wrhen seen in July 1964 he was well, though stillsomewhat
dyspnoeic. On examination the cardiacphysical signs were normal
except for a blood pres-sure of 145/100 mm. Hg. The
electrocardiogram wasessentially unchanged from that before
operation.His chest radiograph showed a normal aortic outlineand
diminution of the transverse cardiac diameter(Fig. 3).
DISCUSSION
Aneurysms of the thoracic aorta may present withsigns of
compression of the surrounding struc-tures, trachea, bronchi,
oesophagus, nerves, bone,and superior vena cava (Boyd, 1924;
Brindleyand Stembridge, 1956; Blakemore and Voorhees,1954; Mills
and Horton, 1938; Kampmeier,1938). Compression of the pulmonary
artery hasnotbeenprevioslydescribed.FIG. 2. Lateral angiogram with
injection of contrastSystolic murmurs are frequently observed in
medium into the right ventricke shows compression andpatients with
aneurysms of the thoracic aorta. distortion of the right
ventricular outflow tract and
Joyce, Fairbairn, Kincaid, and Juergens (1964) pulmonary
artery.
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M. H. Yacoub, M. V. Braimbridge, and R. G. Gold
reported that 50% of a group of 170 patients withaneurysms of
the thoracic aorta had murmurs, butconcluded that it was difficult
to relate them tothe aneurysm and that in most patients themurmurs
'seemed to be non-specific'. Mills andHorton (1938) found that 169
out of 339 patientswith aneurysm of the thoracic aorta had
systolicmurmurs which were best heard in the aortic areain 71, at
the apex in 52, and in the pulmonaryarea in 30 patients. In nine
patients the systolicmurmur was present in all areas and in seven
thesite of the murmur was not specified.
In the case reported here the systolic ejectionmurmur was
unquestionably pulmonary in origin,as it was louder on inspiration,
not conducted tothe neck, and was associated with a
delayedpulmonary component of the second sound.There was a systolic
gradient of 24 mm. Hgbetween the right ventricle and the
pulmonaryartery, and compression of the outflow tract of theright
ventricle and main pulmonary artery wasconfirmed by angiography and
at operation. Theclinical signs of pulmonary outflow
compressionwere relieved completely by resection of theaneurysm.
This suggests that some of the systolicmurmurs described in
association with aneurysmsof the ascending aorta may be due to
pulmonaryoutflow compression.
Obstruction of the right ventricular outflow maytherefore be an
additional factor in the produc-tion of the cardiac enlargement and
failure thatis common in cases of aneurysm, although theseare
usually due to associated syphilitic aortic
FIG. 3. Post-operative radiographshows normal aortic outline
anddiminution of transverse cardiacdiameter.
regurgitation, ischaemic heart disease, or systemichypertension
(Brindley and Schwab, 1930; Millsand Horton, 1938 ; Brindley and
Stembridge,1956). Relief of pulmonary outflow compressionin this
patient resulted in diminution of the heartsize.
Saccular aneurysms of the ascending aorta com-pressing the
pulmonary outflow present specialsurgical problems. When the
aneurysm has anarrow neck the use of cardiopulmonary bypasshas
disadvantages. Mobilization and occlusion ofthe aorta proximal to
the aneurysm to allow thecoronary arteries to be perfused by the
beatingheart is hazardous due to adherence of theaneurysmal sac to
the right ventricle and the rightcoronary and pulmonary arteries.
Clamping theaorta distal to the aneurysm necessitates
coronaryarterial cannulation for myocardial perfusion.This is
difficult to do through ~the narrow neck ofthe aneurysm and may
involve incising normalaortic wall above the aortic ring, which is
oftenobscured by the aneurysm.
These problems do not arise with the use ofprofound hypothermia
by the Drew technique(Drew and Anderson, 1959). With complete
circu-latory arrest at 120 C., proximal control andcoronary
perfusion are unnecessary. The aneurys-mal sac is excised, the neck
closed from inside,and the redundant sac removed, leaving the
partadherent to the pulmonary and right coronaryarteries.The main
hazard of profound hypothermia in
the surgery of thoracic aneurysms is the absence
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Aneurysm of the ascending aorta presenting with pulmonary
stenosis
of clotting during the rewarming phase, whichmay cause
exsanguinating haemorrhage whenplastic prostheses are used because
of uncontroll-able bleeding though stitch holes in the graft.When
the neck is narrow, direct suture of the firmedges of the neck
after opening the sac gives ablood-tight suture line, and
haemorrhage ceasesto be a major problem.
SUMMARY
A case of aneurysm of the ascending aorta pre-senting with signs
of compression of the pul-monary outflow is described. Resection of
theaneurysm resulted in diminution in heart size andimprovement of
symptoms.Profound hypothermia of 120 C. was used to
avoid the necessity for mobilizing the aorta andsac, as the
latter was adherent to the right ventricleand right coronary and
pulmonary arteries.
We would like to thank Mr. N. R. Barrett and Dr.R. V. Gibson for
their permission to publish thiscase.
REFERENCES
Blakemore, A. H., and Voorhees, A. B., Jr. (1954). Aneurysm of
theaorta: a review of 365 cases. Angiology, 5, 209.
Boyd, L. J. (1924). A study of four thousand reported cases
ofaneurysm of the thoracic aorta. Amer. J. med. Sci., 168, 654.
Brindley, P., and Schwab, E. H. (1930). Aneurysms of the aorta,
witha summary of pathologic findings in 100 cases at autopsy.
TexasSt. J. Med., 25, 757.and Stembridge, V. A. (1956). Aneurysms
of the aorta: a clinico-pathologic study of 369 necropsy cases.
Amer. J. Path., 32, 67.
Drew, C. E., and Anderson, I. M. (1959). Profound hypothermia
incardiac surgery. Lancet, 1, 748.
Joyce, J. W., Fairbairn, J. F., Kincaid, 0. W., and Juergens, J.
L.(1964). Aneurysms of the thoracic aorta: a clinical study
withspecial reference to prognosis. Circulation, 29, 176.
Kampmeier, R. H. (1938). Saccular aneurysm of the thoracic
aorta:a clinical study of 633 cases. Akn. intern. Med., 12,
624.
Mills, J. H., and Horton, B. T. (1938). Clinical aspects of
aneurysm.Arch. intern. Med., 62, 949.
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