Mycotic Pseudo-aneurysm of the Ascending Thoracic Aorta After Cardiac Transplantation Nanthini Palanichamy, MD, Igor D. Gregoric, MD, Saverio La Francesca, MD, and Frank W. Smart, MD, FACC A large mycotic pseudo-aneurysm of the ascending thoracic aorta was found in a patient with empyema and infectious mediastinitis after an orthotopic heart transplant procedure. The patient underwent surgical resection of the pseudo-aneurysm with patch aortoplasty and was treated with appropriate long-term antibiotic therapy. The patient continues to do well 3 months after surgery. Early surgical intervention combined with pre-operative and prolonged post-operative antibiotic therapy and close follow-up is essential in these patients. J Heart Lung Transplant 2006;25:730 –3. Copyright © 2006 by the International Society for Heart and Lung Transplantation. Mycotic pseudo-aneurysm of the aorta is a rare and potentially disastrous lesion that, if unattended, ex- poses the patient to false aneurysm rupture and high mortality risk. After cardiac surgery, pseudo-aneurysms may form along aortic suture lines or at sites of aortic cannulation, aortic cross-clamping, cardioplegia needle insertion, aortic vents, or coronary anastomoses. 1,2 Mycotic ascending aortic pseudo-aneurysm is a rare yet life-threatening complication in immunosuppressed heart transplant patients. 3 Only a handful of cases have been described in the literature. 4–7 Herein we describe a patient with gastric perforation after an orthotopic cardiac transplantation. Gastric contents entered the chest and mediastinum, which caused empyema and mediastinitis and led to the formation of an aortic pseudo-aneurysm at the aortic suture line. CASE REPORT A 43-year-old man with a history of cardiopulmonary sarcoidosis came to our institution in 2003 with symp- toms of decompensated heart failure. Cardiac catheter- ization revealed normal epicardial coronary vessels, a severely dilated left ventricle and left atrium, and severe mitral regurgitation. He was prescribed medi- cal therapy and placed on the cardiac transplantation waiting list. In April 2004, he was readmitted to our institution after an episode of decompensated heart failure. His condition continued to deteriorate, and cardiogenic shock and respiratory failure developed despite aggres- sive medical treatment with inotropes and diuretics. An intra-aortic balloon pump (IABP) was inserted to stabi- lize the patient. His condition continued to deteriorate, and he underwent emergent surgery for insertion of a HeartMate IP left ventricular assist system (LVAS) (Tho- ratec Corp., Pleasanton, CA). Post-operative complications included coagulopathy, bleeding, and heparin-induced thrombocytopenia. Two mediastinal explorations were required before the pa- tient’s chest could be closed. His condition eventually stabilized, and the remainder of the post-operative course was uneventful. The patient underwent orthotopic heart transplanta- tion 2 months after LVAD implantation. The early post-operative course was complicated by the develop- ment of right-sided empyema, evidenced by an increas- ing amount of purulent drainage from the right-sided chest tube and confirmed by computed tomography (CT) scanning of the chest. The patient was returned to the operating room and was found to have a gastric perforation. Gastric secretions were spilling into the right chest and mediastinum, causing empyema and mediastinitis, with free communication between the mediastinum and the right pleural cavity. The patient underwent débridement of the mediasti- num in which all foreign body and fibrin deposits were removed, primary repair of the gastric perforation with an omental patch, and right pleural decortication. Ex- tensive intraoperative irrigation was performed using vancomycin, bacitracin, and amphotericin. Operative cultures revealed a vancomycin-resistant strain of En- terococcus and Candida glabrata. The patient was prescribed a low-level immunosup- pressive regimen, and serial endomyocardial biopsies were performed according to the protocol schedule to minimize and better guide the immunosuppressive regimen. He remained on long-term, broad-spectrum antibiotic therapy. The patient was discharged home 50 days after his cardiac transplant surgery. Three months after trans- From the Department of Cardiopulmonary Transplantation, Texas Heart Institute at St. Luke’s Episcopal Hospital, Houston, Texas. Submitted November 7, 2005; revised January 23, 2006; accepted February 11, 2006. Correspondence: Igor D. Gregoric, MD, PO Box 20345, MC 3–147, Houston, TX 77225-0345. Telephone: 832-355-3000. Fax: 832-355- 6798. E-mail: knowlin@heart.thi.tmc.edu Copyright © 2006 by the International Society for Heart and Lung Transplantation. 1053-2498/06/$–see front matter. doi:10.1016/ j.healun.2006.02.009 730