J Cardiovasc Ultrasound.  2013 Dec;21(4):183-185. 10.4250/jcu.2013.21.4.183.

Brucella Endocarditis of Pseudoaneurysm of an Aortic Composite Graft

• Sharifkazemi MB
• Moarref AR
• Rezaian S
• Rezaian GR

• KMID: 2135417
• DOI: http://doi.org/10.4250/jcu.2013.21.4.183

Abstract

The occurrence of Brucella endocarditis following Bentall operation is a rare and life threatening condition, particularly when it is complicated by development of a pseudoaneurysm. Here we present a 40-year-old veterinarian with bicuspid aortic valve, who developed type A aortic root dissection and required Bentall operation. His past medical history was positive for an episode of treated brucellosis. Four months after the operation, he developed signs, symptoms and serological findings of brucellosis for the second time and was treated with antibiotics. Then after he was well untill about 14 days prior to his recent admission, when he again developed hip pain, fever, shortness of breath, profound fatigue and weakness. His transthoracic echocardiography was suggestive of endocarditis. A transesophageal echocardiogram revealed detachment of valve-conduit from the annulus and the mitral-aortic intervalvular fibrosa and the presence of a large aortic pseudoaneurysm with multiple vegetations attached to its Dacron walls. A huge pseudoaneurysm was detected at surgery and the whole valve-conduit was replaced with a 25 mm homograft. Blood and vegetation cultures turned to be positive for Brucella melitensis. Early echocardiographic diagnosis and prompt surgical intervention were helpful for survival of our patient who had aortic pseudoaneurysm complicated by Brucella endocarditis.

Keyword

Aortic valve conduit; Pseudoaneurysm; Brucella endocarditis; Bentall operation

MeSH Terms

Adult
Aneurysm, False*
Anti-Bacterial Agents
Aortic Valve
Bicuspid
Brucella melitensis
Brucella*
Brucellosis
Diagnosis
Dyspnea
Echocardiography
Endocarditis*
Fatigue
Fever
Hip
Humans
Polyethylene Terephthalates
Transplantation, Homologous
Transplants*
Veterinarians
Anti-Bacterial Agents
Polyethylene Terephthalates

Figure

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  Fig. 1 Transesophageal echocardiographic findings of the left ventricular outflow tract and the ascending aorta. A: Mid-esophageal long axis view revealing the detachment of the aortic valve-conduit from the annulus and the mitral-aortic intervalvular fibrosa and the formation of a large pseudoaneurysm with multiple vegetations attached to its walls. B: Color flow mapping showing the simultaneous entrance of blood into the pseudoaneurysm around the Dacron graft and into the aorta. C: Mid-esophageal short axis revealing the pseudoaneurysm surrounding the aortic Dacron graft. The bi-leaflet prosthetic aortic valve is seen as well. D: Color-flow mapping indicating that most of the ejected blood volume enters the pseudoaneurysm rather than the aorta. DG: Dacron graft, LA: left atrium, LV: left ventricle, PA: pseudoaneurysm, PAV: prosthetic aortic valve, V: vegetations.

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  Fig. 2 Long axis views of the ascending aorta showing the compression of the aortic Dacron graft as the blood enters the pseudoaneurysm. Multiple vegetations are visible too. C: compression, PA: pseudoaneurysm, V: vegetations.

Reference

1. Pappas G, Akritidis N, Bosilkovski M, Tsianos E. Brucellosis. N Engl J Med. 2005; 352:2325–2326.

2. Shiono M, Hata M, Sezai A, Iida M, Negishi N, Sezai Y. Reoperation for ascending aortic aneurysm, coronary ostial aneurysm and patent Cabrol trick after bentall operation for aortitis syndrome. Circ J. 2005; 69:861–864.

3. al-Kasab S, al-Fagih MR, al-Yousef S, Ali Khan MA, Ribeiro PA, Nazzal S, al-Zaibag M. Brucella infective endocarditis. Successful combined medical and surgical therapy. J Thorac Cardiovasc Surg. 1988; 95:862–867.

4. San Román JA, Vilacosta I, Castillo JA, Rollán MJ, Sánchez-Harguindey L. Role of transesophageal echocardiography in the assessment of patients with composite aortic grafts for therapy in acute aortic dissection. Am J Cardiol. 1994; 73:519–521.

5. Cianciulli TF, Fairman EB, Saccheri MC, Llanos Dethinne SD, Prezioso HA. Acute supravalvular aortic stenosis following the replacement of the ascending aorta. Eur J Echocardiogr. 2007; 8:232–234.

6. Dhand A, Ross JJ. Implantable cardioverter-defibrillator infection due to Brucella melitensis: case report and review of brucellosis of cardiac devices. Clin Infect Dis. 2007; 44:e37–e39.