Ann Thorac Surg 2009;87:935-936. doi:10.1016/j.athoracsur.2008.07.075
© 2009 The Society of Thoracic Surgeons
Case Reports
Giant Coronary Artery Aneurysm Complicated With Aortic Regurgitation
Kazunobu Hirooka, MD*,
Taijyu Watanabe, MD,
Masahiro Ohnuki, MD
Department of Cardiovascular Surgery, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
Accepted for publication July 16, 2008.
* Address correspondence to Dr Hirooka, Department of Cardiovascular Surgery, Tsuchiura Kyodo General Hospital, Manabe-shinmachi 11-7 Tsuchiura, Ibaraki, 300-0053, Japan (Email: khiro{at}bc4.so-net.ne.jp).
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Abstract
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We present a rare case of a patient diagnosed with aortic insufficiency grade III and a giant coronary artery aneurysm with a maximum diameter of 12 cm. Surgical intervention revealed an incompetent bicuspid aortic valve and a huge thrombosed aneurysm, which communicated with the aorta through the left coronary ostium. In addition to direct closure of the ostium, a saphenous vein was anastomosed to the left anterior descending artery, and the aortic valve was successfully replaced with a mechanical valve.
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Introduction
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Coronary artery aneurysms involving the left main trunk are rarely reported [1, 2]. We present a case of a woman with an occlusive giant coronary aneurysm with moderate aortic regurgitation who had been asymptomatic until congestive heart failure occurred.
A 75-year-old Japanese woman presented with gradually increasing shortness of breath. Clinical examination revealed decreased breath sounds on the left side and a grade III/VI systolic murmur, audible at the right fourth intercostal space. A chest roentgenogram showed severe cardiac enlargement and a prominent bulge on the third arch of the left heart border. An electrocardiogram showed a complete right bundle branch block with ST segment elevation depressions on thoracic leads. A thoracic computed tomographic scan demonstrated a huge aneurysm (10 x 12 cm in diameter) located superiorly to the left atrium and posteriorly to the left pulmonary artery (Fig 1). A fusiform cavity within the aneurysm was 3.5 x 5 cm surrounded by a dense thrombus burden (Fig 2).
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Fig 1. Enhanced computed tomographic scan showing a 3 x 4 cm cavity within the thrombosed aneurysm (maximum diameter, 12 cm).
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Fig 2. A three-dimensional computed tomographic scan shows a cavity within the thrombosed aneurysm (arrowheads) located above the left ventricle. The left anterior descending coronary artery was identified by collaterals from the right coronary artery.
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A transthoracic echocardiogram revealed moderate aortic regurgitation and mildly decreased left ventricular function. Blood flow into the aneurysmal cavity was detected through a hole adjacent to the posterior commissure. A selective coronary angiography showed a totally occluded left coronary artery and the dominant right coronary artery that gave collaterals to the left anterior descending artery. The circumflex system was not visualized. Aortography demonstrated a jet into the cavity from the aortic root with no communication to the coronary arteries.
Surgical exposure by median sternotomy revealed a giant mass with severe pericardial adhesion. The patient was placed on cardiopulmonary bypass through the left femoral artery and right atrial cannulation. The ascending aorta was clamped and cardiac arrest was achieved through retrograde cardioplegia. The aortic valve was bicuspid and unfolded with little coaptation. The right coronary ostium was identified in the anterior Valsalva sinus, and consequently the left coronary ostium was located above the wide commissure (approximately 8 mm) between the anterior and posterior leaflets. The wall of the aneurysm was incised and a large amount of thrombus burden was evacuated. Direct communication between the aorta and the aneurysm was confirmed through the left coronary ostium. After a vein graft was anastomosed onto the left anterior descending coronary artery, intermittent blood cardioplegia was infused through the graft in addition to selective cannulation into the right coronary ostium. No blood flow into the cavity confirmed that the distal entries of both the left anterior descending coronary artery and the circumflex artery were chronically occluded.
The left coronary ostium (6 mm in diameter) was directly closed, and the aortic valve was replaced with a Mosaic 21 mm valve (Medtronic Inc, Minneapolis, MN). The aorta was de-clamped after proximal anastomosis of the vein graft, and the aneurysmal wall was closed by an over and over stitch.
While weaning the patient off cardiopulmonary bypass, moderate bleeding emerged from the anterior aortic root. The heart was re-arrested and a tear (approximately 5 mm in size) was identified in the right side of the aortic root.
After the Mosaic valve was extracted, a Teflon fabric patch (Boston Scientific, Wayne, NJ) was applied to close the tear and a 17-mm St. Jude Medical Regent valve (St. Jude Medical, St. Paul, MN) was reimplanted. The patient was disconnected from cardiopulmonary bypass with a moderate amount of catecholamines.
The patient's postoperative course was uneventful. A postoperative angiogram showed no abnormal communication related to the aneurysm and the patent graft. Histology of the aneurysmal wall revealed marked fibrosis and hyaline formation of media and adventitia with only slight infiltration of leucocytes. The patient has been asymptomatic and a computed tomographic scan at her 6-month follow-up demonstrated a totally thrombosed, shrinking mass (Fig 3).
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Fig 3. Follow-up computed tomographic scan demonstrated shrinkage of the completely thrombosed aneurysm.
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Comment
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The definition of a giant coronary aneurysm remains controversial. We believe that 24 cases have been reported to date in the English literature, with a maximum diameter exceeding 50 mm [3–5]. Our review of the literature has revealed that no previous report has been published on a huge left main thrombosed coronary artery aneurysm, complicated with bicuspid aortic valve regurgitation.
Considering the position of the left coronary ostium and bicuspid leaflets, we believe that congenital malformation in the aortic root may have been involved with this case. Although the histologic specimen was not conclusive, neither atherosclerosis nor inflammatory disease was the least possible cause.
The underlying mechanism of the aortic root bleeding was unclear. As the spontaneous blood pressure recovered, the aneurysmal cavity refilled with diluted serous blood probably originated from aneurysmal wall vessels. One possibility is that the biological valve, seated in the deformed annulus, was compressed to the right by the aneurysm such that the stent post made an injury on the aortic wall. To avoid rupture of the aortic wall again, we decided to switch from the biological valve to an artificial one because of its smaller annulus and lower profile. In addition, drainage of the aneurysmal cavity was continued until the cardiopulmonary bypass was disconnected and protamine sulfate was administered. The complete thrombosed aneurysm on the outpatient computed tomographic scan demonstrated the successful isolation of the aneurysmal cavity from coronary circulation.
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References
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- Hawkins JW, Vacek JL, Smith GS. Massive aneurysm of the left main coronary artery Am Heart J 1990;119:1406-1408.[Medline]
- Lentini S, Raymond G, Cartier P, et al. Surgical treatment of left main coronary aneurysm J Cardiovasc Surg 1994;35:311-314.[Medline]
- Chia HM, Tan KH, Jackson G. Non-atherosclerotic coronary artery aneurysms: two case reports Heart 1997;78:613-616.[Abstract/Free Full Text]
- Mawatari T, Koshino T, Morishita K, Komatsu K, Abe T. Successful surgical treatment of giant coronary artery aneurysm with fistula Ann Thorac Surg 2000;70:1394-1397.[Abstract/Free Full Text]
- Li D, Wu Q, Sun L, et al. Surgical treatment of giant coronary artery aneurysm J Thorac Cardiovasc Surg 2005;130:817-821.[Abstract/Free Full Text]
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Abstract
Introduction
