Coronary Anastomotic Pseudoaneurysm Rupturing into the Right Atrium 22 Years after Aortic Root Replacement

Abstract

A man in his 50s, who had undergone aortic root replacement with a mechanical valve for annuloaortic ectasia in his 30s, presented with epigastric discomfort 22 years after the initial surgery. He was subsequently found to have right-sided heart failure. Contrast-enhanced computed tomography demonstrated a pseudoaneurysm at the right coronary artery anastomosis site. The pseudoaneurysm had ruptured into the right atrium, creating a left-to-right shunt and resulting in right-sided heart failure. Surgical repair included patch closure of the right coronary artery anastomosis, coronary artery bypass grafting to the proximal right coronary artery (#1), and closure of the right atrial shunt. Pseudoaneurysm formation at coronary anastomosis sites has been associated with the inclusion technique during aortic root replacement. The introduction of the Carrel patch technique has markedly decreased the incidence of such aneurysms. Perforation of a pseudoaneurysm into the right atrium remains exceedingly rare. We describe this unusual case of right atrial perforation due to a coronary anastomotic pseudoaneurysm despite the use of the Carrel patch technique, and provide a brief review of the literature.