European Heart Journal Advance Access originally published online on January 31, 2006
European Heart Journal 2006 27(14):1684; doi:10.1093/eurheartj/ehi768
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Dysphagia associated with an aneurysm decades after Blalock–Taussig anastomosis
1 Clinic of Cardiovascular Surgery, German Heart Centre Munich, Lazarettstrasse 36, 80636 Munich, Germany
2 Department of Paediatric Cardiology and Congenital Heart Defects, German Heart Centre Munich, Technical University Munich, Lazarettstrasse 36, Munich, 80636, Germany
* Corresponding author. Tel:+49 8912184111; fax: +49 8912184123. E-mail address: kostolny{at}dhm.mhn.de
A 55-year-old female patient presented with dysphagia and weight loss. The history revealed a diagnosis of Fallot tetralogy (TOF) with right aortic arch. The patient had an original left Blalock–Taussig anastomosis (BTA) performed at the age of 4 and reparative surgery with ligation of the BTA, ventricular septal defect closure, and commissurotomy of the pulmonary valve at the age of 43.
During the routine follow-up on chest X-ray, an enlargement of the upper left mediastinum was seen (Panel A). A computed tomography scan demonstrated a mass extending from left anterior into the posterior mediastinum with proximity to the esophagus posteriorly (Panels B–D), suggesting a partly thrombosed aneurysm.
At repeat operation, the diagnosis was confirmed, and a complete resection of the thrombosed aneurysm with patch closure of the left subclavian artery take-off from the brachiocephalic trunk was performed successfully. The post-operative recovery was uneventful.
The BTA, first performed in 1944, was the earliest of the palliative shunts and has allowed generations of blue babies' long-term survival. This type of operation is associated with a considerable morbidity due to numerous complications (e.g. kinking, occlusion, cardiac failure, pulmonary vascular disease). Aneurysmal degeneration or formation of a pseudoaneurysm is a quite uncommon complication after BTA. Such aneurysms have been found at the systemic end of a ligated shunt and may be related to a large shunt flow and long duration. Moreover, recent findings indicate that marked histological abnormalities exist in the aortic wall in patients with TOF, which may facilitate aneurysm formation.
This report highlights the importance of regular follow-up of adult patients with congenital cardiac defects, even decades after surgery, as these patients are not cured.
Chest X ray and CT scan images of the aneurysm.
Panel A. Chest X-ray demonstrating left upper mediastinal enlargement.
Panel B. Coronary section of the aneurysm.
Panel C. In the sagittal view, the close contact with oesophagus can be appreciated.
Panel D. The transverse section demonstrates the broad origin of the aneurysm. Asterisk indicates aneurysm.
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