Concomitant surgery for Coxiella burnetii aortitis involving zones 2-3 and CABG through left thoracotomy

P0091 

Case Video Submission 

Maria Ascaso Arbona (1), Robert Pruna-Guillen (2), Jorge Alcocer Dieguez (2), Marta Hernandez-Meneses (3), Eduard Quintana (4)

(1) N/A, Canada, (2) N/A, N/A, (3) Infectious Disease - Hospital Clinic, Barcelona, Spain, (4) Hospital Clínic Barcelona Cardiovascular Surgery Department, Barcelona, barcelona

Maria Ascaso    -  Contact Me
N/A

Robert Pruna-Guillen    -  Contact Me
N/A

Jorge Alcocer Dieguez    -  Contact Me
N/A

Marta Hernandez-Meneses    -  Contact Me
Infectious Disease - Hospital Clinic

Eduard Quintana    -  Contact Me
Hospital Clínic Barcelona Cardiovascular Surgery Department

Maria Ascaso    -  Contact Me
N/A

Objective: Q fever is a zoonosis caused by Coxiella burnetii. Aortitis by Coxiella burnetii remains rare and can mimic large vessel giant arteritis. 18FDG-PET/CT provides anatomic characterization and inflammatory activity assessment. Treatment of complicated lesions requires open surgery, which allows for definitive diagnosis.
72-year-old male presented with a 2-month history of fever, malaise and intermittent chest and lumbar pain. CT-scan showed distal arch penetrating ulcer with mural thrombus. TEE ruled out cardiac valve involvement. PET/CT revealed intense FDG uptake on zone 2-3 aortic segment. Serologies suggested active Coxiella burnetii infection. Coronary angiogram confirmed LAD stent re-stenosis (FFR 0.80). Concomitant CABG and aortic replacement through left thoracotomy was indicated.
Methods: 5th intercostal space left thoracotomy access was used. Left internal mammary artery was harvested. The descending thoracic aorta was cannulated using echo guidance (20Fr EOPA) with the cannula tip placed at the level of the proximal arch to reduce the risk of mural thrombus embolization with pump flow. LIMA-LAD was performed while cooling down and the affected aorta was replaced with a 26 mm Ante-Flo graft under deep hypothermic circulatory arrest at 18ºC with whole body retrograde perfusion (HCA-RBP). Surgical video available.
Results: HCA-RBP time was 40 minutes and 317, for cardiopulmonary bypass time. Patient was extubated on postoperative day (POD) 1. Uneventful post-operatory course with no neuro/renal/respiratory complications, discharged on POD 10. Intraoperative cultures and 16S were negative with positive IgG and IgM Coxiella burnetii antibodies. 6 months of Doxycycline 100mg/12h and Levofloxacin 500 mg/24h was completed, then switched to Doxycycline in monotherapy until negative antibodies (total: 18 months). 2 years after, patient is in good health, with no clinical or serological relapses and stable aorta reconstruction
Conclusions: Severe periaortic inflammatory reaction is seen in aortitis and complicates dissection, potentially increasing the iatrogenic risk (phrenic, vagus and esophagus injury). Thorough debridement, along with prolonged antibiotics, are a potentially curative option for complicated Coxiella burnetii aortitis. Whole body retrograde perfusion at the time of arch surgery with proximal open anastomosis allows washout of debris from head vessels and aortic root. CABG can be pursued concomitantly thought the same access

Descending/Thoracoabdominal Aorta