Ann Thorac Surg 1999;67:1780-1782
© 1999 The Society of Thoracic Surgeons
Case Reports
Successful treatment of a ruptured mycotic coronary artery aneurysm
Mark A. Osevala, DOa,
Thomas L. Heleotis, MDa,
Brook A. DeJene, MDa
a Jersey Shore Medical Center, Neptune, New Jersey, USA
Accepted for publication November 5, 1998.
Address reprint requests to Dr Osevala, Jersey Shore Heart Institute, 1944 Route 33, Suite 204, Neptune, NJ 07754
 |
Abstract
|
|---|
Documented mycotic aneurysms of the coronary arteries are unusual, and antemortem identification of such an aneurysm is rare. We present the case of a patient who had successful management of a ruptured mycotic aneurysm of a coronary artery.
|
Introduction
|
|---|
Documented mycotic aneurysms of the coronary arteries are rare. Systemic infection usually accompanies these aneurysms, and they are definitively diagnosed by cardiac catheterization. Prompt surgical treatment including resection of the aneurysm and adjacent necrotic tissue and bypass grafting to a distal vessel is indicated to minimize the risk of distal embolization, myocardial infraction, or rupture with resultant tamponade. We discuss the case of a patient with a ruptured mycotic aneurysm of a coronary artery that was managed successfully.
A 19-year-old man was diagnosed with systemic lupus erythematosus in March 1996 and was seen at Jersey Shore Medical Center with nephrotic syndrome and lupus nephritis at that time. He had been undergoing combination Cytoxan (cyclophosphamide) and high-dose steroid therapy for lupus nephritis 10 days prior to the appearance of symptoms. On admission, he had chills and intermittent left chest pain.
Appropriate blood, urine, and sputum specimens were cultured, and a regimen of intravenous antibiotics was begun. Chest roentgerogram on admission revealed an enlarged cardiac silhouette with no pleural effusions noted. An echocardiogram made the morning after admission revealed a moderate pericardial effusion and no evidence of tamponade. Over the next several hours, the patient’s blood pressure steadily decreased, and pulsus paradoxus developed.
While preparations were made for urgent surgical intervention, the patient sustained a cardiac arrest. He was resuscitated and immediately taken to the operating room. Emergency left anterior thoracotomy and pericardial exploration were carried out. After relief of tamponade, volume infusion, and return of cardiac activity, a thorough and careful investigation of the heart, great vessels, and pericardial sac was undertaken. The site of bleeding was found to be a free rupture of the left ventricle at the base of the left atrium in the vicinity of the circumflex coronary artery.
The incision was converted to a median sternotomy, the patient was placed on cardiopulmonary bypass, and during cardioplegic arrest, careful inspection of the perforation was carried out. The circumflex coronary artery itself was ruptured, and its proximal and distal branches were identified. Both branches were probed and found to be free from substantial atherosclerotic disease. Appropriate cultures from the ruptured area and the myocardium itself were obtained. Necrotic tissue was debrided, and the defect in the left ventricular was repaired using a Teflon patch, reinforced with the appendage of the left atrium. A single reverse saphenous vein bypass graft to a large distal obtuse marginal branch was constructed. The remainder of the operation was completed in the standard fashion, and the postoperative course was without incident.
The patient was discharged on postoperative day 16 and was to complete 6 weeks of intravenous antibiotic therapy. Preoperative blood cultures and intraoperative culture from the ruptured site grew methicillin-sensitive Staphylococcus aureus. Postoperative blood and urine cultures were negative. The postoperative echocardiogram revealed an ejection fraction of 0.60 with no evidence of mitral regurgitation or any valvular abnormalities. At the last clinic visit, the patient was well and remains under the care of an internist for systemic lupus and renal insufficiency.
|
Comment
|
|---|
First described by Morgagni in 1761 as a result of syphilis, mycotic aneurysms of the coronary arteries caused by bacterial infection are rare. Previously, the recognition of mycotic aneurysms was limited to postmortem identification. With the advent of cardiac catheterization and cineangiography, antemortem identification of coronary artery aneurysms resulting from congenital or acquired causes is now possible. With an overall incidence of less than 2% in the general population [1], acquired aneurysms are most commonly atherosclerotic in nature, although other etiologies including dissection, Kawasaki disease, syphilis, and infection have been identified [2]. Spontaneous rupture of a coronary artery aneurysm usually occurs when there is a congenital aneurysm and most often involves the right coronary artery [3].
To date, 15 cases of mycotic aneurysms of the coronary arteries have been reported and are summarized in Table 1 [4]. Bacteriologic identification of the offending organism was complete in five instances; S aureus, was the agent in four, including ours and Streptococcus viridans in one. Prior to our patient, 2 patients had undergone elective surgical treatment of mycotic aneurysm [4, 5]. These patients as well as our patient, were seen with mycotic aneurysms of the left coronary circulation. All 3 patients survived the operation, and 2 patients, 1 being ours, underwent combined resection of the aneurysm and myocardial revascularization using segments of reversed saphenous vein for distal grafting.
In the absence of a prior cardiac, cardiac interventional, or traumatic history the presence of a documented cardiac tamponade, particularly in a young patient, should raise the suspicion of a ruptured coronary artery aneurysm, either congenital or mycotic as a possible etiology [6]. As shown by the case of our patient, prompt surgical intervention is required, and a satisfactory outcome can be achieved.
|
References
|
|---|
-
Hartnelle G.G., Parnell B.M., Pridie R.B. Coronary artery ectasia. Its prevalence and clinical significance in 4993 patients. Br Heart J 1985;34:392-395.[Free Full Text]
-
Wan S., LeClerc J.-L., Vachiery J.-L., Vincent J.-L. Cardiac tamponade due to spontaneous rupture of right coronary artery aneurysm. Ann Thorac Surg 1996;62:575-576.[Abstract/Free Full Text]
-
Letac B., Cazor J.L., Cribier A., Sibille C., Toussaint C. Large multiple coronary artery aneurysm in adult patients: a report on three patients and a review of the literature. Am Heart J 1980;99:694-700.[Medline]
-
Kalangos A., Julia P.L., Ozler A., Jebara V.A., Fabiani J.-N., Sezerman O. Successful surgical treatment of a coronary artery mycotic aneurysm. Ann Thorac Surg 1994;58:1521-1523.[Abstract]
-
Cliff M.M., Soulen R.L., Finestone A.J. Mycotic aneurysms—a challenge and a clue: review of ten-year experience. Arch Intern Med 1970;126:977-982.[Abstract/Free Full Text]
-
Dralle J.G., Turner C., Hsu J., Replogle R.L. Coronary artery aneurysms after angioplasty and atherectomy. Ann Thorac Surg 1995;59:1030-1035.[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
M Taniike, M Nishino, Y Egami, I Kondo, R Shutta, K Tanaka, T Adachi, J Tanouchi, Y Yamada, and K Kawano
Acute myocardial infarction caused by a septic coronary embolism diagnosed and treated with a thrombectomy catheter
Heart,
May 1, 2005;
91(5):
e34 - e34.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
