Hindawi Publishing Corporation
Case Reports in Medicine
Volume 2009, Article ID 740247, 3 pages
DelayedPresentation of a GiantAscendingAortic Aneurysm
TugrulG¨ onc¨ u,1MustafaSezen,1HasanAri,2Osman Tiryakioglu,1G¨ und¨ uzYumun,1
1Department of Cardiovascular Surgery, Bursa Y¨ uksek Ihtisas Education and Research Hospital, Bursa, Turkey
2Department of Cardiology, Bursa Y¨ uksek Ihtisas Education and Research Hospital, Bursa, Turkey
Correspondence should be addressed to Tugrul G¨ onc¨ u, firstname.lastname@example.org
Received 17 October 2009; Accepted 11 December 2009
Recommended by Dieter Horstkotte
Giant ascending aortic aneurysm formation following aortic valve replacement is rare. A 28-year-old man who underwent aortic
valve replacement with a prosthetic valve for aortic regurgitation secondary to congenital bicuspid aortic valve about 10 years ago
was diagnosed with a giant ascending aortic aneurysm about 16cm in diameter in follow-up. The aneurysm was resected leaving
the functional old mechanical prosthesis in place and implanted a 34-mm Hemashield woven graft, associated with the left and
right coronary artery button implantation. Histological findings of the aortic aneurysm wall showed cystic medial necrosis. The
postoperative course was uneventful and postoperative examination demonstrated good surgical results.
Copyright © 2009 Tugrul G¨ onc¨ u et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Patients with bicuspid aortic valve are at increased risk
for aortic complications and that aortic valve replacement
does not prevent progressive aortic dilatation [1, 2]. In
these patients, large ascending aortic aneurysm formation
following aortic valve replacement is very rare but serious
complications with the possibility of rupture or dissection
warrant surgical intervention. Giant aneurysm is defined as
an aneurysm more than 10cm in diameter . We present
a giant ascending aortic aneurysm about 16cm in diameter
which developed after AVR due to bicuspid aortic valve. The
treatment of these aneurysms is a technical challenge and
carries a high morbidity and mortality .
A 28-year-old man with severe aortic regurgitation under-
went aortic valve replacement with a mechanical prosthetic
valve about 10 years ago. At the time of this operation the
ascending aorta was slightly dilated and measured as 3.4cm.
An ascending aortic aneurysm was suspected with chest X-
ray in routine follow-up of the patient who had not been
controlled until that time (Figure 1(a)). Echocardiography
and chest-enhanced computed tomography revealed a giant
ascending aortic aneurysm about 16cm in diameter with
intact aortic arch (Figure 1(b)). Prosthetic valve function
and other cardiac structures were assessed as normal with
two-dimensional and color Doppler examination. An elec-
tive operation was planned for the aortic aneurysm. The
operation was performed under cardiopulmonary bypass,
established by cannulation of the right femoral artery and
right atrium via the right femoral vein. Cardiopulmonary
bypass was started before sternotomy to decompress the
aneurysm. Chest was opened with a median resternotomy. A
giant ascending aortic aneurysm was occupying most of the
(Figure 1(c)). The aortic arch was not found to be involved.
After careful dissection of the aneurysm we were able to
cross clamp the aorta proximally to the brachiocephalic
trunk. After cross-clamping, the aorta was opened and
cardioplegic solution was infused into each coronary artery.
The previously implanted valve prosthesis was intact and
assessment of valve functions was normal. Aneurysm of
the ascending aorta was resected leaving the functional old
mechanical prosthesis in place and we implanted a 34-mm
2 Case Reports in Medicine
Figure 1: (a) Chest X-ray imaging showing as an aortic enlargement. (b) Spiral thoracic computed tomography imaging showing as a 16-cm
aneurysm of ascending aorta. (c) The aortic aneurysm was occupying most of the space in the pericardial cavity. (d) and (e) The aneurysm
of the ascending aorta was resected and implanted with a woven graft associated with the left and right coronary artery button implantation.
Hemashield woven graft (Meadox Medicals Inc, Oakland,
NJ, USA), associated with the left and right coronary artery
button implantation. Distal anastomosis of the aortic graft
was performed under aortic cross clamp (Figures 1(d) and
1(e)). Aortic clamping time was 117 minutes. Weaning from
cardiopulmonary bypass and the postoperative course was
uneventful. The patient was discharged without complica-
tion 10 days after surgery. Marfan syndrome was clinically
excluded. Histological findings of the aortic aneurysm wall
showed cystic medial necrosis (Figure 2).
Aortic complications occurring after aortic valve replace-
ment (AVR) include aortic dissection, ascending aortic
aneurysm, aortic root aneurysm, and pseudoaneurysm [1–
4]. To our knowledge, current case is one of the largest true
ascending aortic aneurysm published in the literature which
developed after AVR.
The presented case had been operated before for severe
aortic regurgitation secondary to congenital bicuspid aortic
valve. Bicuspid aortic valve (BAV) is one of the most
common congenital disorders involving the heart valves,
with a prevalence ranging from 1% to 2% of the entire
population . Data from several groups [2, 4, 5] demon-
strated that patients with BAV are at increased risk for
aortic complications, even late after aortic valve surgery,
because of histopathological changes in the ascending aorta,
predisposing one to aneurysm development and dissection.
There is evidence to suggest an intrinsic smooth muscle
abnormality which leads to a higher rate of cystic medial
degeneration in those patients with congenitalbicuspid valve
disease [4–6]. In the present case, the histopathological find-
ings of aneurysmal tissue were consistent with medial cystic
degeneration. Association between BAV and cystic median
necrosis of the aorta relates to a common embryologic origin
of the aortic valve and of the aorta itself [1, 5]. The aorta of
a patient with a BAV contains less elastic tissue as compared
Case Reports in Medicine3 Download full-text
Figure 2: Pathological findings are demonstrating typical cystic
medial degenerative changes. Histologically, it had the appearance
in the media of “cystic spaces” filled with mucoid materials (arrow).
(Hematoxylin & Eosin, original magnification × 100).
to a normal (tricuspid) aortic valve . Specifically, patients
with a BAV have thinner elastic lamellae of the aortic media
and greater distances between the elastic lamellae than in
patients with a normal aortic valve [1, 2]. Patients with
BAV are at increased risk for aortic complications and that
aortic valve replacement does not prevent progressive aortic
dilatation [2, 6]. In a study of 35 patients (20 patients
with BAV) undergoing aortic valve replacement with aortic
diameters greater than 40mm the authors noted that 5
arising from this paper is for all patients undergoing AVR
with an ascending aorta greater than 40mm should have
their ascending aorta replaced at the same time . Borger
et al.  suggested that patients undergoing operations
for BAV disease should be considered for concomitant
replacement of the ascending aorta if the diameter is 4.5cm
or greater. Recent guidelines from the American College
of Cardiology/American Heart Association confirm such a
strategy . However, not all patients with BAV will develop
aortic dilatation over time. Nistri et al.  observed a 52%
prevalence of aortic dilatation in a series of young patients
with normally functioning BAV.
Based on the law of Laplace, wall tension increases as
the radius of an aneurysm increases (tension = pressure ×
radius). It is therefore intuitive that larger aneurysms have a
greater risk of rupture. Coady et al.  have written exten-
sively on the natural history of thoracic aortic aneurysms.
Logistic regression analysis of the data revealed a 4.3-fold
increased risk of rupture or dissection in an aneurysm 6.0 to
6.9cm in diameter compared to an aneurysm 4.0 to 4.9cm
in diameter. Growth rates varied from 0.08cm per year for
greater than 8.0cm in diameter. In the current case, the
aneurysm grew the relatively larger size without rupture
adhesions which were present in mediastinal and periaortic
region secondary to first operation and the long-term use of
beta blockers in the current case might prevent the aneurysm
to rupture and give rise to the larger diameters.
We believe that the patients with congenital BAV should be
formation even if their aortic valve is replaced. The surgical
management of aortic aneurysm should be done in order
to decrease the morbidity and mortality in those patients
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