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CASE REPORT
Year : 2022 | Volume
: 8
| Issue : 3 | Page : 188-190
Pseudoaneurysm formation between ascending aorta and main pulmonary artery following ventricular septal defect patch dehiscence
Guriqbal Singh1, Mrugesh Prajapati1, Jigisha Pujara1, Trushar Gajjar2, Bhavik Chimpaneri3, Pavan Patel3
1 Department of Cardiac Anaesthesia, U.N. Mehta Institute of Cardiology and Research Center, Civil Hospital Campus, Ahmedabad, Gujarat, India
2 Department of Cardiothoracic and Vascular Surgery, U.N. Mehta Institute of Cardiology and Research Center, Civil Hospital Campus, Ahmedabad, Gujarat, India
3 Department of Pediatric Cardiology, U.N. Mehta Institute of Cardiology and Research Center, Civil Hospital Campus, Ahmedabad, Gujarat, India
Correspondence Address:
Jigisha Pujara
Department of Cardiac Anaesthesia, U.N. Mehta Institute of Cardiology and Research Center, Civil Hospital Campus, Asarwa, Ahmedabad - 380 016, Gujarat
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/jpcs.jpcs_70_22
Complications of ventricular septal defect (VSD) repair include arrhythmias, tricuspid valve insufficiency, and residual shunt. We are presenting a unique and extremely rare complication of rupture of VSD patch, leading to the formation of pseudoaneurysm between the ascending aorta and main pulmonary artery following VSD patch closure.
Keywords: Pseudoaneurysm, transthoracic echocardiography, ventricular septal defect
A 3-month-old infant weighing 3.2 kg presented to our hospital with a history of recurrent episodes of upper respiratory tract infections and was diagnosed with a perimembranous ventricular septal defect (VSD) and coarctation of the aorta. The patient was operated on for VSD closure along with arch repair for coarctation of the aorta.
The patient's postoperative course was complicated by sepsis and prolonged mechanical ventilation due to difficulty in weaning in the pediatric intensive care unit (PICU). Surgical tracheotomy was eventually performed. Repeated transthoracic echocardiography (TTE) of the patient at 2 months was suggestive of dehiscence of the VSD patch below the pulmonary valve with large residual VSD [Figure 1] and [Figure 2]. A large pseudoaneurysm was developed between ascending aorta and main pulmonary artery (MPA) arising from the left ventricle of size 35 mm × 20 mm. Adjacent sinus of the pulmonary valve was deficient, causing severe Pulmonary Regurgitation (PR). There were additional two noncommunicating cyst-like structures superior to pseudoaneurysm of size 24 mm × 20 mm and 11 mm × 11 mm, respectively [Figure 3]. It revealed moderate-to-severe Pulminary Artery Hypertension (PAH). Computed tomography pulmonary and aortic angiography confirmed the findings of TTE and showed patent pseudoaneurysm of maximum dimension 40 mm × 35 mm × 35 mm at the level of VSD repair site communicating with subvalvular aortic as well as main pulmonary trunk [Figure 4]. Surgical repair of pseudoaneurysm along with VSD closure was planned. The patient was posted for the revision surgery for pseudoaneurysm and VSD.
Figure 1: Transthoracic echocardiography showing ruptured VSD patch and deficient pulmonary valve. VSD: Ventricular septal defect.
Figure 3: TTE showing multiloculated pseudoaneurysm. TTE: Transthoracic echocardiography.
Figure 4: CT pulmonary and aortic angiography showing pseudoaneurysm between ascending aorta and main pulmonary artery at VSD level. VSD: Ventricular septal defect, CT: Computed tomography.The patient was shifted to the operating room and a multiparameter monitor including electrocardiogram, pulse oximetry (spO2), and noninvasive blood pressure was applied to the patient. 4.5 Ft right internal jugular and central venous line were already in situ for central venous pressure monitoring. Pediatric external defibrillator pads were applied. Injection of fentanyl 15 
g and injection of vecuronium 30 g were given. The right femoral artery cannulation was done for intra-arterial pressure monitoring. Cardiopulmonary bypass (CPB) was instituted by peripheral vascular cannulation after giving 400 IU/kg of injection heparin and achieving activated clotting time of more than 480s. Following the oblique left flank incision, arterial cannulation was done in the left external iliac artery through a 3.5 mm polytetrafluoroethylene (PTFE) graft anastomosed to the left external iliac artery, and venous cannulation was done through the external iliac vein. On achieving 40% of pump flows, midline incision and sternotomy were done, pseudoaneurysm was visualized and dissected, and right atrial (RA) cannulation was done. Full CPB flows were achieved. After giving aortic root cardioplegia and applying cross-clamp, dissection was completed. Pseudoaneurysm was arising from the pulmonary artery, having subcommissural origin [Figure 5]. Endothelialization over the dehiscent PTFE patch was seen. Leaflets of pulmonary valve were torn and fibrosed. VSD was closed through transpulmonary artery approach and the PTFE patch was applied in such a way, that pseudoaneurysm opening was obliterated. The pulmonary valve and tricuspid valve leaflets facing the aorta were excised and the anterior leaflet was preserved. Pseudoaneurysm wall was cut and closed. The patient was rewarmed and successfully weaned off from CPB with loading dose of injection milrinone 50 g/kg and injection of adrenaline 0.04 g/kg/min. RA and pulmonary arterial blood gas analysis was done and no step up in the saturation was observed. Heparin was reversed with 15 mg of injection protamine. Decannulation was done and after the completion of surgery, the patient was shifted to PICU. Postoperative TTE showed no residual flow and mild tricuspid regurgitation (TR).
Mortality for uncomplicated VSD repair in infants during the first year of life is <5%.[1] Conduction disorders are common and well-recognized complications in the postoperative period following VSD repair.[2] Common conduction defect following VSD repair includes complete heart block, junctional ectopic tachycardia, and right bundle branch block.[3] Other complications are tricuspid valve insufficiency, residual shunt, septal hematoma, and VSD patch dehiscence.[4] The incidence of residual shunt is 0.7%–2%.[5] Kawashima et al.[6] reported a case of left ventricular pseudoaneurysm formation following dehiscence of VSD patch 7 years after the repair. However, in this case, an unusual complication was seen post-VSD patch closure, where the PTFE patch was torn leading to the formation of multiloculated pseudoaneurysm formation between ascending aorta and MPA. It prolonged the duration of mechanical ventilation in this patient and led to the failed weaning of the patient. The intraoperative course was challenging in terms of biventricular dysfunction, difficult weaning from CPB, anticipated risk of major vessel injury following sternotomy in redo surgery, unique cannulation for the institution of CPB, and closure of pseudoaneurysm. TTE is an inevitable and indispensable tool for anesthesiologist.[7] TTE helped in diagnosing the cause of weaning failure in this patient and helped in the formulation of further management plans for this patient.
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The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient's parent(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patient's parents understand that their his names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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