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A 63-year-old woman presented with a 1-month history of progressing sternal mass.
She underwent mechanical aortic valve replacement (AVR) with a St Jude 19 mm valve
(St. Jude Medical, Saint Paul, MN) and Manougian annulus enlargement technique 10
years ago for aortic stenosis. She had an unremarkable clinical follow-up and a normal
transthoracic echocardiography (TTE) 5 years ago. Four months before the current event,
she had a transient episode of severe chest pain for which she did not seek medical
attention. Physical examination revealed a pulsatile sternal mass and a IV-VI grade
murmur with a thrill. There was no evidence of infection; she had normal blood analyses
and negative blood cultures. Chest radiography showed enlarged mediastinum with a
broken sternal wire. Transesophageal echocardiography showed normal AVR function with
minimal regurgitation (Fig. 1). Computed tomography angiography (CTA) revealed a large aortic pseudoaneurysm measuring
10.5 × 5.4 × 6.7 cm originating from the aortic annulus and extending through the
sternum to the subcutaneous tissues (Fig. 2). Soft tissue (35 to 50 Hounsfield units pre- and postcontrast) was observed within
the pseudoaneurysm, most in keeping with a mural thrombus. There was a partial compression
of the right pulmonary artery and right atrium. The patient remained hemodynamically
stable throughout the investigations.
Figure 1Preoperative chest radiography and transoesophageal echocardiography (TEE). (A) Posteroanterior and (B) lateral chest radiography showing an abnormal right mediastinal and anterior chest
wall bulging (white arrows) and broken sternal wire (red arrow on lateral view). (C) TEE showing the absence of aortic regurgitation.
Figure 2Pre- and postoperative gated contrast-enhanced computed tomography angiography (CTA).
(A) Coronal view showing the pseudoaneurysm and mural thrombus. (B) Zoomed view on the rupture site just above the aortic valve prosthesis. (C) Sagittal view demonstrating the pseudoaneurysm extension through the sternum. (D) Three-dimensional reconstruction of the pseudoaneurysm eroding the sternum. (E) Postoperative CTA in axial and (F) sagittal views showing the ascending aorta repair without residual pseudoaneurysm.
2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.
2022 ACC/AHA guideline for the diagnosis and management of aortic disease: a report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines.
