Mycotic False Aneurysm of the Aorta Following Aortic ... fileAortic Valvular Prosthesis A Case Report ByNOBUHISABABA,M.D.,ANDTREVORL. McKIssIcK, M.D. SINCE the introduction of the

Mycotic False Aneurysm of the Aorta FollowingAortic Valvular Prosthesis

A Case Report

By NOBUHISA BABA, M.D., AND TREVOR L. McKIssIcK, M.D.

SINCE the introduction of the Starr-Edwards ball valve1 into cardiac surgery

in 1961, a number of successful operationshave been recorded. This is a case report of amycotic false aneurysm of the ascending aortaresulting in fatal incompetence of the pros-thetic valve.

Case ReportA 39-year-old white man with acute rheumatic

fever at the age of 19 years remained asymptoma-tic until 3 years before demise, when he startedto have fainting episodes associated with chestpain and one year later symptoms of congestiveheart failure.

Examination at the Ohio State University Hos-pital showed signs of aortic stenosis, and cardiaccatheterization revealed a pressure gradient of90 mm. water across the aortic valve. He under-went open-heart surgery for the placement of aStarr-Edwards prosthetic valve in the aortic osti-um. The postoperative course was complicatedby anemia and wound infection with a coagulase-positive Staphylococcus but he responded totreatment fairly well. Four months after the op-eration the patient developed fatigue, occasionalfever, and chills. One week before his last ad-mission he noted petechiae, dyspnea, and ortho-pnea. Five months after the operation he wasagain admitted to University Hospital.On physical examination at this admission the

patient was slightly dyspneic, the temperaturewas 100.2 F., and the blood pressure was 112/40.The neck veins were minimally distended at 300position. The lungs revealed bilateral rales, par-ticularly in the bases. The heart rate was regularat 87 per minute. The point of maximal impulsewas in the sixth intercostal space at the leftanterior axillary line. There were a grade-V/'VIholosystolic regurgitant murmur throughout theprecordium radiating to the left axilla, a grade-III/VI systolic ejection murmur in the rightsecond intercostal space radiating toward the

From the Department of Pathology, The OhioState University, Columbus, Ohio.

Circulation, Volume XXXI, April 1965

apex, and a grade-III/VI high-pitched blowingdiastolic murmur along the left sternal border,intense in the third intercostal space. A promi-nent opening snap was heard. The liver edge wasfelt two fingerbreadths below the right costalmargin. Pretibial and pedal edema was present,and petechiae were seen over the extremities.The nail beds showed splinter hemorrhages.The patient's hemoglobin was 7.9 Gm. per

100 ml., the hematocrit level 25 per cent; reti-culocytes 3.3 per cent; total leukocytes 10,400per mm.3 The half-life of Cr5'--tagged erythro-cytes was 732 days, and the blood smear showedpyknocytosis. The blood urea nitrogen was 39mg. per 100 ml. All 12 blood specimens grew acoagulase-negative Staphylococcus. On radiologicexamination the prosthesis was in place. Theelectrocardiogram suggested incomplete bundle-branch block and left ventricular hypertrophy.The patient was given 40 million units of in-

travenous penicillin daily and his fever camedown. One week after admission the chest woundstarted to drain and again a coagulase-positiveStaphylococcus was cultured. A radiologic exam-ination suggested widening of the ascending aortadue to an aortitis. Three weeks after admissionthe anterior chest abscess was noted to pulsate,and an attempt at incision and drainage wasgiven up. On the forty-sixth hospital day thepatient's temperature suddenly rose to 102 andpetechiae spread over the skin. A radiologic exam-ination at this time showed excessive rockingmotion of the prosthesis, indicating loosening ofthe valve from its attachment. The valve was seenat an angle of 700. His blood pressure changedto 110/0, and an electrocardiogram showed sec-ond-degree heart block. He died on the forty-ninth hospital day.

Autopsy FindingsOn the chest wall of the body was a partially

healed scar running from the suprasternal notchto the xiphoid process, showing a few areas ofbreakdown from which a very small amount ofexudate was drained. The subcutaneous tissuecontained small abscesses. In the right pleuralcavity were 50 ml. of serous fluid; in the left, 75ml. The entire pericardial cavity was loosely

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fibrosed. The heart, ini-cluing the artificial valveand an-i aneurysm, wveighed 780 Gmn. The leftatrium was moderately (lilated. The left ventriclemeasured 18 to 20 mm. in thickness; the right,3 to 4 mm. The mnvocardiuim of the posterior-xvall showed sevei al patchy areas of fibrosis. Theiartificial valve was movable and1t was sututred tothe ainnuiltus onlvy in the posterior sinuiis, andl in thesiriuis the Nvioni suituries lhadl been torni- fr-om thewall leavinig dlefects. Six m-iillimeters above thecommissure betweeni the posterior- aind left sinuseswas an organ-iized thrombils oni the aor-ta with acenitral depression having the coniformationi of thestirface of the plastic ball-valve. This thrombusprobably formedn whlen the prostlhesis movedlslightly to the left. The xvidest separation- of theprosthesis fr-oin the aortic wall was in the riglitsinus. Also in the r-ight sinus wall there was atriangular- defect 3 cm. in width and in heightat and above the level of the prosthetic ring. Aniirregular fibrin mplass 2 cm. in diameter was at-tached on the artificial ring. The defect formedthe opening of a false anieuriysm between the as-cernding aorta, the remaining right atrium, andlthe right lung. The aneurysmal space measured5 by 3 by 2 cm. an-d contained fresh and clottedblood. The ouiter wxall consisted of denise post-surgical fibrous adhesions, and the ininer surfacevas lined by or-ganized thrombi (fig. 1). Therewere also many organized fibrinimasses on theeindocardiuim of the subvalvuilar reglion althoughnio defect was seeni in this area. The base of thetriangle lay along the previotus valvular annuluis.The previous surgiecal inicisioni was intact and(Ienidothelixmm covered the Nylon sutures at theincision of the aorta, xvhich rarn vertically 1 cm.to the left of the rupture (fig. 2). The rest of theaortic root was slightly widened and showed only

Figure 1

Anetirysm. A: anientrysnmal ltimetn. Arrow: opening ofaineutrysni.

Figure 2

Hoot of aorta. I: in1tact incision linie. T: thmroboticmtiaterial ont p)rosthesis itndicatinig 1both bacteria 1 1(lo-carditis andl p-resetnce of aortic instfficiency at tlitsportion. Arrowc: op)ening of acnenirylsini.

small atheromiatouis plaquties. Neither coron-arvostium wvas in-ivolvedl. The right artery was ver-Vhypoplastic. The anterior descending branch ofthe left coroniary artery showed a pin-hole lumen3 cm. from the ostiuim. The ball valve was par-tial-ly endothelialized. The other valves showved nodleformities. The annu-lllar circumfer-ences of themitral and tricuspid valves were increased.The right Ilung xveighed 500 Cm., the left 4530

Gm. Both lunigs shoxxed edema, congestion, andfocal atelectasis. The liver weighed 1,850 Cm.and showed moderate congestion. The spleenweighed 300 Gm. and showed areas of mycoticinfarction. The right kidney weighed 150 Gm.and the left kidney 300 Gm.; thev showed severecongestion and cloudy swelling.The verrucous material attached to the aorta

and the prosthesis xvas mainlly fibrin wxith rareaggregates of neutrophils; no bacterial coloniiesvere seeni. There were several pieces of hyalinizedtissue xvith occasional calcification originatinigfrom the annulus of the valve. This mass was inotendothelialized. The aorta showed moder-ate in-timal ulceration, but the most remarkable changesvere seen in the ouiter med:ia and the adventitia;these changes consisted of heavy proliferation ofchronic granuilation tissue with many capillaries,fibroblasts, and histiocytes. Occasional hemoside-rin deposits were founiid. In the area of rupture themedia appeared abruptly torn and the edge wassurrounded by the granulation tissue; no degenera-tive process wvas noted in the elastic laminae. Thebase of the aneurysm was composed of dense,partially hyalinized fibrous tissue covered with athick layer of fibrin which contained numerouis

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\IYCOTIC FALSE ANEURYSNI

FiguLre 3

Sit' of aoileic jptmr. Ao,ow: stun;) of muedia sitr-rounded hby granldatioi tlissnt(:. Aneurysmal lutmen is

ott righit.

pus cells. MaIny pigmient-laden niacrophages werealso seen (fig. 3).The section-is fr omii Ilunigs, liver-, spleen, anid

kicnevxs conifirmed the gross interpretation. NoeinI)olic focal glonmerulitis was present.

DiscussionMycotic aneurysm of the aorta is relatively

uinicomnmon, as shown by Parkhurst and Deck-er," xvho reviewed 22,792 autopsies at theB3ostoin City Hospital performed betxveen 1902and 1951 and found only 12 cases of bacterialaortitis, nine of whiclh w ere associated withaneutrsmi. Earlier, Auerbach revievewd 135cases of purulent aortitis, including 15 casesof his owvn. Aneeurysm formation was seen in58 of them. Edwards4 showed several caseillustrations of mycotic aneurysms associatedwvith bacterial endocarditis. Onie case had my-cotic aneulrysms originating from the posterioraortic sinutis, muichl as the aneturysm in our case

was located.Most of the mycotic aneurysms in the as-

cending aorta xere associated xvith bacterialendocarditis of the aortic valve,'I although my-cotic aneurysm may l)e observed follovingCirculation, Volume XXXI, April 1965

syphilitic aortitis,;i atlherosclerosis, anid dissect-inig aneurysM.2 Some lesionis in the high as-

cending aorta, as reporte(l by Merkel," maybe seconidary to remote traulma. Isolated my-cotic aneurysmns are rare anld are uisually as-sociated with clhronic septicemia, remote bac-terial infections,8 or congenital malformations,ssuch as hypoplasia" and coarctation.1'" Thleworganiisms reach the aorta tlhrouiglh the vxasavasorumi, t7ith or tvithout eml)olism, an(l theintima is relatively tininivolved.Aneurysm formation followilug aortic valve

surgery is either traumatic or mycotic. Camp-be11" reported a traumiatic false aneurysm ofthe ascending aorta 13 months after the de-l)ridement of the aortic valve for calcific ste-nosis. The aneuirysm was suiccessfully ligated.Eliot et al."2 reported a trauimatic false aneu-ryvsm followixlug needle puincture of the aorta.The patient died of staphylococcal inediastini-tis. Hadorn"' noted a m-nycotic aneurysm duieto extension of aspergillus endocarditis fol-loving the removal of calcified subaortic ste-IlOSiS.

In the majority of cases bacterial aortitis,xvith or withouit aneurysm, is caused by gram-positive cocci, particularly pneumococci andstreptococci. Parkhurst and Decker found sixpneumococcal and two streptococcal infec-tions among 12 cases. Auerbach reviewed 70cases of aortitis with bacterial studies andfouind streptococci in 26 cases, pnieuimococciin 12, and staphylococci in eight cases. Ed-wards4 presented several cases of mycoticaneurysms catused by streptococci and Staphl-yllococcus auretIs. Gram-negative bacilli are

rarely implicated, but Salmonella inifect thearteriosclerotic aneurysmis of the abdominalaorta.'4 According to Rob and Ngu,"' staph-ylococci xvere often the causative agents in theprimary mycotic aneurysms of the lower aortaand its major brainches. Apparently chronicstaphylococcal sepsis was an-i imnportant fac-tor. In all but one case the staphylococei wereof the auireuLs group.

Coagulase-negative staphylococcal infec-tion, as seen in our case, is rather uinuisuial.The heavy peniicillin treatmnent givein for thishighly (drugi-sensitive organiism cotuld not clear

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the active inflammatory process in the falseaneurysm. The chronic inflammatory processwithin the aortic wall was still in active prog-ress and contributed to the terminal tear ofthe prosthesis and incompetence of the valve.

SummaryA case of a mycotic false aneurysm of the

ascending aorta and aortic sinus caused bycoagulase-negative staphylococcal endocarditisfollowing the placement of a Starr-Edwardsprosthesis for rheumatic aortic stenosis is re-ported. The formation of the aneurysm causedaortic insufficiency, and terminally the pros-thesis was torn from the aorta. The occurrenceof mycotic aneurysms in the aorta and theiretiology and pathogenesis are discussed. Casesof postoperative false-aneurysm formation ofthe ascending aorta are reviewed.

References1. STARR, A., AND EDWARDS, M. L.: Mitral replace-

ment: the shielded ball valve prosthesis. J.Thor. & Cardiov. Surg. 42: 673, 1961.

2. PARKHURST, G. P., AND DECKER, J. P.: Bacterialaortitis and mycotic aneurysm of the aorta. Areport of twelve cases. Am. J. Path. 31: 821,1955.

3. AUERBACH, 0.: Beitrage zur Kenntnis der eitrigeAortitis. Virchow Arch. path. Anat. 286: 268,1932.

4. EDWARDS, J. E.: An Atlas of Acquired Diseasesof the Heart and Great Vessels, Vol. I, Diseasesof the Valves and Pericardium. Philadelphia,W. B. Saunders Co., 1961.

5. CURRENS, J. H., AND FAULKNER, J. M.: Gono-coccal mycotic aneurysm of the aorta: Reportof a case superimposed upon a syphilitic aorta.Ann. Int. Med. 19: 155, 1943.

6. MERKEL, H.: Zirkulare Aortenruptur und Aneury-sma spurium bei eitriger Aortitis. Zentralbl.Allg. Path. 86: 227, 1950.

7. SIEGMUND, H.: Ueber nicht syphilitsche Aortitis:Pathologisch-anatomische Demonstration zurFrage der Gefasswandverainderungen bei All-gemeininfektionen. Ztschr. Kreislaufforsch. 21:389, 1929.

8. REVELL, S. T. R., JR.: Primary mycotic aneurysms.Ann. Int. Med. 22: 431, 1945.

9. CRANE, A. R.: Primary multilocular mycoticaneurysm of the aorta. Arch. Path. 24: 634,1937.

10. ROB, C., AND NGU, V.: Mykotische Aneurysmenunklarer Aetiologie. Deutsch. med. Wchnschr.85: 1157, 1960.

11. CAMPBELL, G. S.: Injury of the thoracic aorta:Selective review and case report of repair offalse aneurysm thirteen months after the aorticvalve surgery. Am. J. Surg. 105: 462, 1963.

12. ELIOT, R. S., LEVY, M. J., LILLEHEi, C. W., ANDEDwARDs, J. E.: False aneurysm of the as-cending aorta following needle puncture andcross-clamping. J. Thor. & Cardiov. Surg. 47:248, 1964.

13. HADORN, W. (1961). Cited by DOERR, W.: Path-ologie der herznahen grossen Gefasse. In Doerr,W., and Bargmann, W. (Ed.): Das Herz desMenschen, Vol. II, p. 894. Stuttgart, G. ThiemeVerlag, 1963.

14. SILBERMAN, S., AND GREENBLATT, M.: Primarymycotic aneurysm of the aorta: A complica-tion of salmonellosis. Angiology 14: 372, 1963.

As no two faces, so no two cases are alike in all respects, and unfortunately it is notonly the disease itself which is so varied, but the subjects themselves have peculiaritieswhich modify its action.-Sm WILLIAM OSLER. Aphorisms From His Bedside Teachingsand Writings. Edited by William Bennett Bean, M.D. New York, Henry Schuman,1950, p. 34.

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NOBUHISA BABA and TREVOR L. MCKISSICKCase Report

Mycotic False Aneurysm of the Aorta Following Aortic Valvular Prosthesis: A

Print ISSN: 0009-7322. Online ISSN: 1524-4539 Copyright © 1965 American Heart Association, Inc. All rights reserved.

is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231Circulation doi: 10.1161/01.CIR.31.4.575

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