Background: Ascending aortic pseudoaneurysm at a proximal graft anastomosis is an uncommon yet life-threatening complication following coronary artery bypass grafting. Clinical presentation may mimic postoperative cardiac tamponade or constrictive physiology.
Case Presentation: A 55-year-old man presented two weeks after coronary artery bypass grafting with progressive dyspnea, abdominal distension, and bilateral leg edema. Physical examination revealed tachycardia, elevated jugular venous pressure, muffled heart sounds, ascites, and significant peripheral edema. Electrocardiography demonstrated sinus tachycardia with low-voltage QRS complexes, while chest radiography indicated marked cardiomegaly. Urgent transthoracic echocardiography identified a 12 x 15 cm retrosternal cystic lesion anterior to the heart and ascending aorta, with systolic color Doppler flow from the ascending aorta into the cavity. These findings were consistent with a giant pseudoaneurysm resulting from dehiscence of the proximal saphenous vein graft anastomosis to the right coronary artery. Due to severe hemodynamic compromise, emergency reoperation was performed. Cardiopulmonary bypass was established via femoral arterial and venous cannulation prior to sternal re-entry, as the pseudoaneurysm was located immediately beneath the sternum. Surgical exploration confirmed anastomotic dehiscence. The pseudoaneurysm was evacuated and resected, and the graft anastomosis was repaired with direct Prolene suture. The patient recovered without complications.
Conclusion: Giant ascending aortic pseudoaneurysm may develop rapidly following coronary artery bypass grafting and present with right-sided heart failure and constrictive or tamponade-like physiology. Timely echocardiographic assessment and prompt surgical intervention are critical for patient survival.