Supravalvular aortic stenosis caused by compression of a pseudoaneurysm late after aortic root replacement

We present a case of supravalvular aortic stenosis (SVAS) caused by compression of a pseudoaneurysm. A 69-year-old female presented with worsening dyspnea and chest pain. Ten years earlier, she experienced an acute aortic dissection and underwent emergency aortic root replacement with a mechanical valve, along with coronary artery bypass grafting to the right coronary artery (RCA) (Fig. 1a). A harsh systolic murmur was auscultated over a wide area of the precordium. No ischemic symptoms or signs were observed in the brain or upper extremities. Chest X-ray showed an increase in the cardiothoracic ratio compared to previous images, with congestion. An electrocardiogram did not show any ST-T changes. Transthoracic echocardiography (TTE) showed a slightly dilated left ventricle (LV), LV ejection fraction (LVEF) of 55%, hypokinesis of the basal inferior wall, and moderate mitral regurgitation (MR). Previous TTE measurements had shown an LVEF of 66% with no wall motion abnormalities. Although no abnormalities were noted in the aortic root (Fig. 1b) and in the prosthetic valve, the graft was compressed by a mass, resulting in SVAS (Fig. 1c–e). Contrast-enhanced CT revealed that the graft was compressed by the mass, leading to SVAS (Fig. 1f–h). The mass was enhanced, so the mass identified on TTE was confirmed as a pseudoaneurysm. The saphenous vein graft (SVG) was not opacified, but the RCA remained patent (Fig. 1g, h). During emergency surgery, blood flow entering the pseudoaneurysm was observed at the distal anastomosis of the graft, and the SVG was completely disrupted from the graft. The distal anastomosis was revised with a new graft, and a SVG was anastomosed between the graft and the RCA. Postoperative TTE showed a reduction in LV size, and the LVEF improved to 62%. Furthermore, the hypokinesis of the basal inferior wall and the MR resolved.

…