Thorax (1966), 21, 236.

Aneurysm of the ascending aorta presenting withpulmonary stenosis

M. H. YACOUB, M. V. BRAIMBRIDGE,1 AND R. G. GOLD

From the Brornpton Hospital, London S.W.3

The symptoms and signs of aneurysms of thethoracic aorta are due mainly to compression ofsurrounding mediastinal structures and depend onthe size and location of the aneurysm. Compres-sion of the trachea, bronchi, oesophagus, recurrentlaryngeal nerve, bone, and superior vena cava iscommon, but pressure on the pulmonary artery hasnot been described in spite of its intimate relationto the ascending aorta.The object of this paper is to describe a case

presenting in this way and to discuss the particularsurgical problems involved in the excision of suchan aneurysm.

CASE REPORT

E. D., a man aged 52 years, was admitted to theBrompton Hospital in December 1963. He had ahistory of healed bilateral pulmonary tuberculosis,and he suffered from recurrent attacks of haemoptysisand bronchial infection. In January 1957 he had beenadmitted to hospital in acute cardiac failure due tocoronary thrombosis. Since then he had beenmoderately dyspnoeic.On examination he was a heavily built man. The

pulse was in sinus rhythm, the blood pressure 120/80 mm. Hg, and the jugular venous pressure wasnormal. An abnormal systolic impulse was palpablein the second left intercostal space at the left sternaledge. There was a moderately loud, harsh, inspira-tory pulmonary ejection murmur, and the pulmonarycomponent of the second sound was delayed andreduced in intensity but moved on respiration. Bi-lateral basal crepitations were heard in the lungs,and the liver was palpable one finger's breadthbelow the costal margin.The electrocardiogram showed sinus rhythm with a

normal PR interval. The mean frontal QRS vectorwas -40°, and there was right bundle-branch blockwith a terminal R' deflection in V1 of 13 mm. Thesechanges were interpreted as indicating ischaemic heartdisease.

'Preseat address: Cardiac Surgical Unit, St. Thomas's Hospital,London S.E.1

The chest radiograph (Fig. 1) showed old bilateralapical tuberculosis, and both lungs were emphyse-matous. The emphysema was most marked in the leftupper lobe with bullae present. A hemispherical mass,9 by 6 cm., lay to the left and in front of the ascend-ing aorta. Its border was slightly irregular. andshowed flecks of linear calcification laterally andsuperiorly. The heart size was within normal limits.At right heart catheterization difficulty was experi-

enced in passing the catheter into the pulmonaryartery. The right ventricular systolic pressure was44 mm. Hg and the pulmonary artery systolic pres-sure was 18 mm. Hg. the systolic gradient being 24mm. Hg, with a single change in pressure fromarterialto ventricular configuration in the vicinity of thepulmonary valve. The angiogram (Fig. 2) showedcompression and distortion of the right ventricularoutflow tract, pulmonary valve, and main pulmonaryartery by a mass lying above and in front of them.The aortic valve and lower part of the ascending aortawere normal. A saccular aneurysm, measuring 8 by5-5 cm., arose from the upper part of the ascendingaorta and contained clot. The neck of the sac was2 5 cm. in diameter. The Wassermann, Price's preci-pitin reaction, Treponema pallidum immobilization,Reiter protein complement fixation test, cardiolipinWassermann, and fluorescent treponemal antibodytests were all negative.

Repair of the aneurysm was performed on 14 May1964 with the aid of profound hypothermia by theDrew technique, using a bilateral transverse incisionalong the lower border of the third rib dividing thesternum. The circulation was arrested for 35 minutesat a temperature of 12° C. The aneurysmal sac wasopened and the neck was seen to be 2 5 cm. in dia-meter, with strong fibrous margins. Direct suture ofthe defect in the aortic wall was performed withinterrupted mattress sutures and reinforced with acontinuous running stitch and a pericardial flap. Two-thirds of the sac was removed and the remainder wasobliterated by sutures. During rewarming of thepatient there was no bleeding from the suture line.The emphysematous bullae in the left upper lobe

were obliterated by multiple catgut ligatures, a tech-nique that avoided the air leak which is inevitablewith excision and suture. The chest was closed and atracheostomy was performed.

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Aneurysm of the ascending aorta presenting with pulmonary stenosis23

FIG. 1. Pre-operative radiograPh showsaii ascending aortic aneurysm and healedapical tuberculosis and emphysema.

Artificial ventilation was required for three weeks,following which the patient made an uneventfulrecovery. The pulmonary ejection murmur dis-appeared immediately after operation.

Wrhen seen in July 1964 he was well, though stillsomewhat dyspnoeic. On examination the cardiacphysical signs were normal except for a blood pres-sure of 145/100 mm. Hg. The electrocardiogram wasessentially unchanged from that before operation.His chest radiograph showed a normal aortic outlineand diminution of the transverse cardiac diameter(Fig. 3).

DISCUSSION

Aneurysms of the thoracic aorta may present withsigns of compression of the surrounding struc-tures, trachea, bronchi, oesophagus, nerves, bone,and superior vena cava (Boyd, 1924; Brindleyand Stembridge, 1956; Blakemore and Voorhees,1954; Mills and Horton, 1938; Kampmeier,1938). Compression of the pulmonary artery hasnotbeenprevioslydescribed.FIG. 2. Lateral angiogram with injection of contrastSystolic murmurs are frequently observed in medium into the right ventricke shows compression andpatients with aneurysms of the thoracic aorta. distortion of the right ventricular outflow tract and

Joyce, Fairbairn, Kincaid, and Juergens (1964) pulmonary artery.

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M. H. Yacoub, M. V. Braimbridge, and R. G. Gold

reported that 50% of a group of 170 patients withaneurysms of the thoracic aorta had murmurs, butconcluded that it was difficult to relate them tothe aneurysm and that in most patients themurmurs 'seemed to be non-specific'. Mills andHorton (1938) found that 169 out of 339 patientswith aneurysm of the thoracic aorta had systolicmurmurs which were best heard in the aortic areain 71, at the apex in 52, and in the pulmonaryarea in 30 patients. In nine patients the systolicmurmur was present in all areas and in seven thesite of the murmur was not specified.

In the case reported here the systolic ejectionmurmur was unquestionably pulmonary in origin,as it was louder on inspiration, not conducted tothe neck, and was associated with a delayedpulmonary component of the second sound.There was a systolic gradient of 24 mm. Hgbetween the right ventricle and the pulmonaryartery, and compression of the outflow tract of theright ventricle and main pulmonary artery wasconfirmed by angiography and at operation. Theclinical signs of pulmonary outflow compressionwere relieved completely by resection of theaneurysm. This suggests that some of the systolicmurmurs described in association with aneurysmsof the ascending aorta may be due to pulmonaryoutflow compression.

Obstruction of the right ventricular outflow maytherefore be an additional factor in the produc-tion of the cardiac enlargement and failure thatis common in cases of aneurysm, although theseare usually due to associated syphilitic aortic

FIG. 3. Post-operative radiographshows normal aortic outline anddiminution of transverse cardiacdiameter.

regurgitation, ischaemic heart disease, or systemichypertension (Brindley and Schwab, 1930; Millsand Horton, 1938 ; Brindley and Stembridge,1956). Relief of pulmonary outflow compressionin this patient resulted in diminution of the heartsize.

Saccular aneurysms of the ascending aorta com-pressing the pulmonary outflow present specialsurgical problems. When the aneurysm has anarrow neck the use of cardiopulmonary bypasshas disadvantages. Mobilization and occlusion ofthe aorta proximal to the aneurysm to allow thecoronary arteries to be perfused by the beatingheart is hazardous due to adherence of theaneurysmal sac to the right ventricle and the rightcoronary and pulmonary arteries. Clamping theaorta distal to the aneurysm necessitates coronaryarterial cannulation for myocardial perfusion.This is difficult to do through ~the narrow neck ofthe aneurysm and may involve incising normalaortic wall above the aortic ring, which is oftenobscured by the aneurysm.

These problems do not arise with the use ofprofound hypothermia by the Drew technique(Drew and Anderson, 1959). With complete circu-latory arrest at 120 C., proximal control andcoronary perfusion are unnecessary. The aneurys-mal sac is excised, the neck closed from inside,and the redundant sac removed, leaving the partadherent to the pulmonary and right coronaryarteries.The main hazard of profound hypothermia in

the surgery of thoracic aneurysms is the absence

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Aneurysm of the ascending aorta presenting with pulmonary stenosis

of clotting during the rewarming phase, whichmay cause exsanguinating haemorrhage whenplastic prostheses are used because of uncontroll-able bleeding though stitch holes in the graft.When the neck is narrow, direct suture of the firmedges of the neck after opening the sac gives ablood-tight suture line, and haemorrhage ceasesto be a major problem.

SUMMARY

A case of aneurysm of the ascending aorta pre-senting with signs of compression of the pul-monary outflow is described. Resection of theaneurysm resulted in diminution in heart size andimprovement of symptoms.Profound hypothermia of 120 C. was used to

avoid the necessity for mobilizing the aorta andsac, as the latter was adherent to the right ventricleand right coronary and pulmonary arteries.

We would like to thank Mr. N. R. Barrett and Dr.R. V. Gibson for their permission to publish thiscase.

REFERENCES

Blakemore, A. H., and Voorhees, A. B., Jr. (1954). Aneurysm of theaorta: a review of 365 cases. Angiology, 5, 209.

Boyd, L. J. (1924). A study of four thousand reported cases ofaneurysm of the thoracic aorta. Amer. J. med. Sci., 168, 654.

Brindley, P., and Schwab, E. H. (1930). Aneurysms of the aorta, witha summary of pathologic findings in 100 cases at autopsy. TexasSt. J. Med., 25, 757.and Stembridge, V. A. (1956). Aneurysms of the aorta: a clinico-pathologic study of 369 necropsy cases. Amer. J. Path., 32, 67.

Drew, C. E., and Anderson, I. M. (1959). Profound hypothermia incardiac surgery. Lancet, 1, 748.

Joyce, J. W., Fairbairn, J. F., Kincaid, 0. W., and Juergens, J. L.(1964). Aneurysms of the thoracic aorta: a clinical study withspecial reference to prognosis. Circulation, 29, 176.

Kampmeier, R. H. (1938). Saccular aneurysm of the thoracic aorta:a clinical study of 633 cases. Akn. intern. Med., 12, 624.

Mills, J. H., and Horton, B. T. (1938). Clinical aspects of aneurysm.Arch. intern. Med., 62, 949.

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