From the Guidelines
A pseudoaneurysm is a serious complication of endocarditis, where infection erodes through the heart tissue, creating a contained rupture of a blood vessel or the heart wall, and its management should prioritize early detection and surgical repair with debridement of infected tissue and reconstruction, along with appropriate antibiotic therapy, as recommended by the 2015 ESC guidelines for the management of infective endocarditis 1. In the context of endocarditis, pseudoaneurysms can develop as a result of abscess formation in the myocardium or valve annulus, which can rupture into a cardiac chamber, creating a pseudoaneurysm. These structures are particularly dangerous because they lack the normal vessel wall layers and are prone to expansion and rupture, which can cause life-threatening hemorrhage, fistula formation, or embolization. The diagnosis of pseudoaneurysms associated with endocarditis typically requires echocardiography (particularly transesophageal), CT angiography, or cardiac MRI, as outlined in the 2015 ESC guidelines 1. Some key points to consider in the management of pseudoaneurysms associated with endocarditis include:
- Early detection and management are crucial as rupture carries a high mortality rate
- Surgical repair with debridement of infected tissue and reconstruction, along with appropriate antibiotic therapy, is usually necessary
- The management of pseudoaneurysms should be provided by an Endocarditis Team, including cardiologists, cardiac surgeons, ID specialists, microbiologists, and other experts, as recommended by the 2015 ESC guidelines 1
- The use of imaging techniques, such as echocardiography, MRI, MSCT, and nuclear imaging, is important for diagnosis, follow-up, and decision-making in patients with pseudoaneurysms associated with endocarditis, as outlined in the 2015 ESC guidelines 1.
From the Research
Definition of Pseudoaneurysm
- A pseudoaneurysm is a disruption of an artery with patent flow in a defined space beyond the confines of the vessels 2.
- It can involve any vascular bed and is usually associated with direct arterial injury or erosion of an artery by an adjacent tumor or inflammation 2.
Relation to Endocarditis
- Pseudoaneurysms can occur in patients with endocarditis, particularly those with periannular pseudoaneurysms 3.
- The presence of a pseudoaneurysm in endocarditis patients is associated with a high mortality rate 3.
- Pseudoaneurysms in endocarditis are often located in the aortic position and around prosthetic material 3.
- Left ventricular pseudoaneurysms can develop in the setting of infective endocarditis, resulting from remodeling of extravalvular abscesses 4.
Clinical Presentation and Treatment
- Pseudoaneurysms can present with varying symptoms, from being clinically silent to a life-threatening emergency scenario 5.
- Treatment options for pseudoaneurysms include ultrasound-guided thrombin injection, stent graft repair, coil embolization, and surgery 5, 2.
- In cases of endocarditis, medical treatment without surgery may be considered when no other surgical indications exist 3.
- Delayed diagnosis of endocarditis can lead to fatal complications, including pseudoaneurysm formation 6.