INFECTIVE ENDOCARDITIS WITH MECHANICAL AORTIC AND MITRAL VALVES

INFECTIVE ENDOCARDITIS WITH MECHANICAL AORTIC AND MITRAL VALVES REPLACEMENT COMPLICATED BY SPONTANIOUS ASCENDING AORTIC DISSECTION AND RUPTURE 20 YEARS LATER. 1 MD , Aref Obagi Dawn M. Calderon Benjamin A. Youdelman Jersey Shore University Medical Center, Neptune NJ. [1] Department of Medicine [2] Department of Cardiology [3] Department of Cardiothoracic Surgery. LEARNING OBJECTVES • Identifying ascending aortic dissection and rupture in a patient with remote history of infective endocarditis who underwent mechanical aortic and mitral valves replacement (AVR and MVR). • Survival rates and poor prognostic factors in patients with ascending aortic dissection. CASE PRESENTATION • 52 -year-old male with past medical history of infective endocarditis status post mechanical aortic and mitral valves replacement 20 years prior to admission. • Patient was in his usual state of health until he developed sudden onset of severe chest pain. • CT scan with contrast of the chest done in the emergency department revealed rupture of the ascending aorta with partial dissection of the distal ascending aorta. (Figure 1) 2 MD , 3 MD HOSPITAL COURSE • Patient was sent emergently to the operating room where he had successful reconstruction of the ascending aorta and transverse arch using Vascutek Gelweave graft. • Patient was neurologically intact after the surgery and he was discharged day 9 post-op. OUTPATIENT FOLLOW-UP • At four months follow-up visit, patient was doing well and the repeated CTA of the chest revealed no evidence of pseudo-aneurysm or leak around the graft (Figure 2). DISCUSSION • The incidence of ascending aortic dissection or type A dissection is estimated 5 -30 cases per one million people per year 1. • Aortic valve replacement is considered a risk factor for developing ascending aortic dissection. • In a published study 2 looked at 2202 patient who underwent AVR due to aortic valve disease between years 1982 -1996, 8 patients developed ascending aortic dissection (5 patients had acute presentation similar to our case, one of them died in the OR). The interval between AVR and developing ascending aortic dissection ranged from four months to 10 years 2. • Poor prognostic factors for ascending aortic dissection include perioperative bleeding and massive blood transfusion 3 , rupture of the thoracic aorta 3 , previous AVR 4 , age >705, abrupt onset of chest pain 5. • According to IRAD ( International Registry of Acute Aortic Dissections registry) 1 and 3 -year survival rate of patients with acute ascending aortic dissection treated surgically was 96% and 90% respectively 6. SUMMARY Figure 2: CT of the chest, Sagittal view, four months post surgical reconstruction. (yellow asterix) PRE AND POST SURGERY IMAGES • In summary, we are reporting a rare case of a patient who had infective endocarditis resulted in mechanical aortic and mitral valves replacement complicated by ascending aortic dissection and rupture 20 years later and it was successfully repaired with an emergent surgical intervention. REFERENCES Figure 1: CT of the chest with contrast, Sagittal view, Aortic rupture (red arrow). Figure 3: CT with contrast done on the day of admission showing aortic dissection (red arrow). Figure 4: four months post-op and resolution of the aortic dissection (yellow arrow). [1] The Gale Encyclopedia of Medicine. 3 rd ed. Stamford, Conn: Gale; 2008 [2] Milano A 1, Pratali S, De Carlo M, Borzoni G, Tartarini G, Bortolotti U. Ascending aorta dissection after aortic valve replacement. J Heart Valve Dis. 1998 Jan; 7(1): 75 -80. [3] Chiappini B, Schepens M, Tan E, Dell' Amore A, Morshuis W, Dossche K Bergonzini M, Camurri N, Reggiani LB, Marinelli G, Di Bartolomeo RE. ur Heart J. 2005; 26(2): 180. [4] Miller DC, Mitchell RS, Oyer PE, Stinson EB, Jamieson SW, Shumway NE, Circulation. 1984; 70(3 Pt 2): I 153 [5] Mehta RH, O'Gara PT, Bossone E, Nienaber CA, Myrmel T, Cooper JV, Smith DE, Armstrong WF, Isselbacher EM, Pape LA, Eagle KA, Gilon D. J Am Coll Cardiol. 2002; 40(4): 685 [6] Tsai TT 1, Evangelista A, Nienaber CA, Trimarchi S, Sechtem U, Fattori R, Myrmel T, Pape L, Cooper JV, Smith DE, Fang J, Isselbacher E, Eagle KA; Circulation. 2006 Jul 4; 114(1 Suppl): I 350 -6.