Echocardiographic diagnosis of Pseudoaneurysm of the aortic root in a chronically critically ill child
Presented By:
Ricardo Argueta-Morales, MD; María J. Reyes, MD; Mirna Álvarez, MD; Evelyn D. Ramos, MD
Pediatric Cardiology, Unidad de Cirugía Cardiovascular de Guatemala; Hospital General San Juan de Dios; and Universidad de San Carlos de Guatemala
dr.argueta@gmail.comOverview:
Introduction: Pseudoaneurysm of the aortic root (PAR) is a rare diagnosis in children. It presents as an outpouching of the aorta caused by a defect in the tunica intima and media. PAR may lead to rupture, dissection, or valvar insufficiency, so prophylactic root replacement is indicated. This defect is typically seen in children in the setting of connective tissue disorders. We report our experience diagnosing PAR as a complication of endocarditis, using transthoracic and transesophageal echocardiograms complemented by MRI imaging, and managing a chronically critically ill child at Unidad de Cirugía Cardiovascular de Guatemala (UNICAR).
Case description: Thirteen-year-old male admitted for severe dengue at public health hospital. Patient was mechanically ventilated (MV) and required vasoactive medications, blood transfusions, antibiotics, and total parenteral nutrition. Course of illness was complicated with infections including meningitis, endocarditis, and pressure ulcers leading to osteomyelitis. Patient was weaned from MV after 48-days. On day-74 of admission, echocardiogram at UNICAR reported right atrial vegetation and antithrombotic therapy began. The vegetation was not found on follow-up echocardiogram 1 month later. After mild improvement, a new echocardiogram was requested because erythrocyte-sedimentation-rate elevation. Echocardiogram reported aortic periannular abscess that evolved into PAR. Cardiac MRI confirmed these findings.
Discussion: We present a chronically critically ill patient that developed PAR as a complication of bacterial endocarditis. Management of this patient continues to be challenging due to development of multiple concomitant pathologies. PAR is considered a rare, life-threatening complication of endocarditis, valve surgery, genetic disorders, or trauma. Diagnosis of PAR is mainly done by echocardiogram. On initial transthoracic echocardiography (TTE), our patient was found to have a 13x8.3mm aortic abscess above the right coronary sinus. Follow-up TTE 1 month later found the typical PAR imaging of an echolucid, pulsatile cavity, with flow inside of it and diastolic expansion indicating its communication with the aorta. Transesophageal echocardiography has superior diagnostic sensitivity than TTE; however, TTE is the major imaging modality for diagnosis and assessment of complications in children. Cardiac MRI is useful as a complementary study to determine the pseudoaneurysm extent and its relationship with neighboring structures. Our patient is still taking enoxaparin and is being managed conservatively for PAR as he continues to be hospitalized and treated for other comorbidities. No evidence of thrombosis has been documented. We continue to provide close echocardiographic monitoring and planning for optimal time for surgical treatment.
Conclusions: Accurate diagnosis of PAR in children can be done with echocardiography. Cardiac MRI is recommended as an adjunct study for surgical planning as it provides further anatomic details of PAR. Conservative management of uncomplicated/asymptomatic PAR may be considered in pediatric patients; however, further studies are needed to determine the best management approach for of this defect.
Case description: Thirteen-year-old male admitted for severe dengue at public health hospital. Patient was mechanically ventilated (MV) and required vasoactive medications, blood transfusions, antibiotics, and total parenteral nutrition. Course of illness was complicated with infections including meningitis, endocarditis, and pressure ulcers leading to osteomyelitis. Patient was weaned from MV after 48-days. On day-74 of admission, echocardiogram at UNICAR reported right atrial vegetation and antithrombotic therapy began. The vegetation was not found on follow-up echocardiogram 1 month later. After mild improvement, a new echocardiogram was requested because erythrocyte-sedimentation-rate elevation. Echocardiogram reported aortic periannular abscess that evolved into PAR. Cardiac MRI confirmed these findings.
Discussion: We present a chronically critically ill patient that developed PAR as a complication of bacterial endocarditis. Management of this patient continues to be challenging due to development of multiple concomitant pathologies. PAR is considered a rare, life-threatening complication of endocarditis, valve surgery, genetic disorders, or trauma. Diagnosis of PAR is mainly done by echocardiogram. On initial transthoracic echocardiography (TTE), our patient was found to have a 13x8.3mm aortic abscess above the right coronary sinus. Follow-up TTE 1 month later found the typical PAR imaging of an echolucid, pulsatile cavity, with flow inside of it and diastolic expansion indicating its communication with the aorta. Transesophageal echocardiography has superior diagnostic sensitivity than TTE; however, TTE is the major imaging modality for diagnosis and assessment of complications in children. Cardiac MRI is useful as a complementary study to determine the pseudoaneurysm extent and its relationship with neighboring structures. Our patient is still taking enoxaparin and is being managed conservatively for PAR as he continues to be hospitalized and treated for other comorbidities. No evidence of thrombosis has been documented. We continue to provide close echocardiographic monitoring and planning for optimal time for surgical treatment.
Conclusions: Accurate diagnosis of PAR in children can be done with echocardiography. Cardiac MRI is recommended as an adjunct study for surgical planning as it provides further anatomic details of PAR. Conservative management of uncomplicated/asymptomatic PAR may be considered in pediatric patients; however, further studies are needed to determine the best management approach for of this defect.
