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Ann Thorac Surg 2001;71:1688-1690
© 2001 The Society of Thoracic Surgeons
a Division of Cardiopulmonary Surgery, Oregon Health Sciences University, Portland, Oregon, USA
Accepted for publication May 12, 2000.
* Address reprint requests to Dr Cobanoglu, 1944 SW Palatine Hill Rd, Portland, OR 97219
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Abstract |
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Introduction |
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A 63-year-old man with an abnormal cardiac silhouette was referred for surgical opinion. He had been having nonproductive cough for the previous 7 months, with a 10-day exacerbation of symptoms before admission. A recent episode of chest pain and an episode of transient atrial fibrillation that responded to digoxin were documented.
General examination was unremarkable. The patient was in sinus rhythm, afebrile, and normotensive. Jugular venous pressure was not elevated, and there were no features of cardiac failure. Heart sounds were of normal intensity, with a split S2. A grade 4/6 systolic murmur was audible over the left sternal border. Systemic examination was otherwise normal.
Electrocardiogram showed sinus rhythm with right bundle branch block. Chest roentgenogram showed an aneurysmal MPA segment with no cardiomegaly and normal lung fields. Computed tomographic scan of the chest revealed aneurysmal dilatation of the MPA starting 2 cm above the valve with generous branch pulmonary arteries. Fluoroscopy confirmed these findings. Cardiac catheterization documented right atrial mean pressure of 4 mm Hg, right ventricular pressure of 40/5 mm Hg, pulmonary arterial pressure of 30/10 mm Hg (with one peak of 48/22 mm Hg), pulmonary capillary wedge pressure of 6 mm Hg, and aortic pressure of 120/70 mm Hg. No intracardiac shunt was documented. Coronary angiography revealed mild irregularities in both left and right coronary systems, with no discrete lesions. Pulmonary angiography (Fig 1) with digital subtraction was done. It showed a large aneurysm of the MPA extending down the left pulmonary artery. The valve annulus was normal, and there was no regurgitation. The patient was investigated thoroughly for systemic vasculitis, and this workup was negative.
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Large aneurysms can be unstable. The dynamics are dictated by Laplace’s law, where wall tension is directly proportional to the intravascular pressure and radius of the vessel and is inversely related to the wall thickness. The thinner the vessel wall and the higher the intravascular pressure, the greater the chance for vessel dilatation or even rupture [5].
Evaluation should include echocardiography, cardiac catheterization, and angiography to exclude intracardiac pathology; study of the hemodynamic profile; and evaluation of the coronary arteries. Pulmonary angiography probably represents the gold standard for evaluation of the extent of the aneurysm. Magnetic resonance imaging has emerged as a useful noninvasive imaging modality that is ideal for detection of possible intimal flaps and for long-term follow-up of the size of the aneurysm [6].
In the opinion of some workers [7], surgical repair (interposition of Dacron [DuPont] prosthesis or homograft, reconstruction with pericardial patch, aneurysmorrhaphy or arterioplasty) is recommended when these aneurysms are discovered. Others [6] believe that surgery should be advised only when the risk to the patient is acceptably low, when a progressive and constant increase in the arterial diameter is well documented, or in the presence of dissection. Main pulmonary artery aneurysms probably do not warrant the same aggression as aneurysms of the aorta do, especially if pulmonary artery pressures are normal. Because our patient was in his 60s, we chose the simpler, more straightforward method of plication angioplasty in the hope of buying him another couple of symptom-free decades. Patients symptomatic from dyspnea, chest pain, hemoptysis, or the large size of the aneurysm probably need surgical intervention owing to the risk of rupture [8]. Our patient recovered fully and remained asymptomatic at 4-month follow-up.
There are very few reports in the literature of MPA aneurysms with no underlying pathology. The presence of symptoms and the potential risk of enlargement and rupture were the rationale for accepting the patient in this report for surgery.
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