Difficulties in myocardial protection, tactics and surgical technique in the surgical treatment of a giant pseudoaneurysm of the ascending aorta

We present the case of a 65 years old patient, initially hospitalized at Regional Pneumology Clinic with marked fatigue, severe pulmonary symptoms (suddenly developed severe resting dyspnea, orthopnea, irritating cough), loss of appetite, weight loss and dysphagia. Chest radiography raises the suspicion of giant ascending aortic aneurysm. Echocardiography confirms the presence of the aneurysm, but CT scan with contrast and angiography showed a giant pseudoaneurysm of ascending aorta with severe local compression of the right lung hilum and right main bronchus and in posterior on the esophagus. Coronary angiography also shows significant compression and deformation of the left main coronary artery. Echocardiography reveals marked dilated ascending aorta in the suprabulbar portion without aortic insufficiency. Replacement of the ascending aorta was performed in extracorporeal circulation with a impregnated Dacron prosthesis. Because of technically difficult approach, the ascending aorta ( being the right anterolateral wall of the pseudoaneurysm) was incanculated via right axillary artery, the aortic crossclamp was performed initially transluminal with Foley catheter and later with classical metallic instruments, and myocardial protection was achieved initially by retrograde administration of cardioplegic solution with monitoring of lactic acid, pH and base excess simultaneous from coronary sinus and the coronary ostia during administration of cardioplegic solution. The postoperative evolution was favorable, the weaning from extracorporeal circulation was succeeded without inotropics, with a 48 hours length of stay in ICU, and the patient was discharged after 8 days postoperatively.