PMC7307618_01
Electrocardiogram: sinus rhythm (92 bpm) and aspecific repolarization alterations (negative T-wave in aVR, aVL, and V1-V2)
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F1
T-waves in aVR, aVL, V1, and V2 (unvaried compared to previous) [Figure 1]; high sensitivity troponin value was 100 ng/L (n. v. <19.8 ng/L), so the patient was admitted in cardiology care unit. Transthoracic echocardiography (TTE) showed a large aortic graft pseudoaneurysm and a shunt from aortic graft to periprosthetic false aneurysm (PPFA) not reported in previous echocardiographies [Figure 2].
Parasternal long-axis view of transthoracic echocardiography: color Doppler shows a shunt from vascular aortic prosthesis (asterisk) to periprosthetic false aneurysm. Quality of image does not allow a better definition
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F2
T-waves in aVR, aVL, V1, and V2 (unvaried compared to previous) [Figure 1]; high sensitivity troponin value was 100 ng/L (n. v. <19.8 ng/L), so the patient was admitted in cardiology care unit. Transthoracic echocardiography (TTE) showed a large aortic graft pseudoaneurysm and a shunt from aortic graft to periprosthetic false aneurysm (PPFA) not reported in previous echocardiographies [Figure 2].
Axial plane of computed tomography angiography: large aortopulmonary fistula is visualized between vascular aortic prosthesis and pulmonary artery trunk(*)
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F3
For better ascending aorta visualization, computed tomography (CT) scan with contrast was performed: it confirmed the presence of large pseudoaneurysm surrounding the aortic graft and found an APF between the pseudoaneurysm and the pulmonary trunk [Figure 3].
Electrocardiogram during chest pain shows sinus rhythm (93 bpm) and ST elevation in the right leads (aVR, V1, V2, and V2R)
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F4
Besides he had acute chest pain, an EKG promptly carried out showed ST elevation in the right leads [Figure 4] which improved after nitrates iv administration.
Coronary angiography: left coronary artery is normal (a), the right coronary artery is not visualized (b) due to failure to pass a guidewire across the right coronary button anastomosis
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F5
Urgent coronary angiogram, aortography, and right heart catheterization were performed: the left coronary artery was normal [Figure 5a] and the right coronary artery was not visualized due to failure to pass a guidewire across the right coronary button anastomosis [Figure 5b]; aortopulmonary fistula (QP/QS = 2.7) and postcapillary pulmonary hypertension pulmonary artery wedge pressure (PAWP): 25 mmHg and mean pulmonary arterial pressure (mPAP): 35 mmHg) were confirmed.
Cardiac surgery: in a pseudoaneurysm (white asterisk) and pericardial patch (white arrow) and in b aortic vascular prosthesis (black asterisk) and right coronary ostium closure (black arrow) are visualized.
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F6
Surgical treatment was performed across four steps: saphenous vein graft to right coronary artery, pericardial patch to close the APF, right coronary ostium closure, and saphenous vein anastomosis to Bentall prosthesis [Figure 6].