Open Approach of Ascending Aorta Septic Rupture

BACKGROUND: Septic pseudoaneurysms of the native ascending aorta are rare and challenging to treat, especially in elderly, comorbid patients with septic conditions and unfavorable anatomy for endovascular repair. CASE SUMMARY: A 78-year-old man with prior tricuspid valve replacement for endocarditis presented with methicillin-sensitive Staphylococcus aureus bacteremia. Imaging showed a large ascending aorta pseudoaneurysm, likely at the previous cardioplegia site. He underwent successful surgical repair via direct bovine pericardial patch closure under normothermic cardiopulmonary bypass. Recovery was uneventful. DISCUSSION: Endovascular repair requires suitable anatomy, including adequate landing zones and small neck size, which were lacking here. Direct surgical patch repair offers a safe, effective, and less-invasive alternative to full aortic replacement, especially in septic, frail patients. TAKE-HOME MESSAGES: Multidisciplinary heart team discussion is essential to tailor management for complex septic aortic pseudoaneurysms. When endovascular treatment is unfeasible, direct surgical patch repair remains a safe and effective option in selected patients.