Asian Cardiovasc Thorac Ann 2006;14:422-424
© 2006 Asia Publishing EXchange Ltd
Cardiac Tamponade Due to Spontaneous Rupture of Large Coronary Artery Aneurysm
Satoshi Kimura, MD,
Kazuyuki Miyamoto, MD,
Yasutaka Ueno, MD
Department of Cardiovascular Surgery, Shimonoseki Municipal Central Hospital, Yamaguchi, Japan
For reprint information contact: Satoshi Kimura, MD Tel: 81 92 642 5557 Fax: 81 92 642 5566 Email: sakimura{at}heart.med.kyushu-u.ac.jp, Department of Cardiovascular Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
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ABSTRACT
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A 70-year-old woman admitted with chest pain went into shock due to cardiac tamponade; 1000 mL of blood was drained from her pericardium. Enhanced computed tomography showed massive pericardial effusion and a coronary artery aneurysm in front of the main pulmonary artery. Coronary angiography revealed a coronary artery-pulmonary artery fistula and 3 giant saccular coronary artery aneurysms. Emergency surgical repair was successful.
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INTRODUCTION
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Coronary artery aneurysm has been reported in 1.4% of postmortem examinations.1 Recently, it has become easy to detect by coronary angiography. Coronary artery aneurysm usually causes few symptoms, and rupture is rare; however, once it happens, it can be lethal due to cardiac tamponade. We describe a case of acute cardiac tamponade caused by spontaneous rupture of a coronary artery aneurysm with a coronary arteriovenous fistula.
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CASE REPORT
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A 70-year-old woman, who had no prior cardiac or thoracic trauma history, experienced sudden chest pain. A week later, the pain recurred and she went to a nearby hospital where an echocardiogram showed cardiac tamponade. She went into shock and was treated with pericardial drainage; approximately 1,000 mL of blood was discharged. She recovered with catecholamine administration and blood transfusion, and was immediately transferred to our hospital where chest radiography showed an enlarged cardiac silhouette and mediastinal widening. Enhanced computed tomography revealed massive pericardial effusion and a mass in front of the main pulmonary artery, but no evidence of acute aortic dissection which we had expected to find (Figure 1
). Therefore, aortography was carried out, which revealed 3 giant coronary artery aneurysms with a coronary arteriovenous fistula (Figure 2). Two of the aneurysms drained into the pulmonary artery and originated from a relatively small branch of the left anterior descending artery, and another arose from the origin of the right coronary artery.
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Figure 1. Computed tomography of the chest showed an aneurysmal mass (arrow) ahead of the main pulmonary trunk, and no evidence of acute aortic dissection. Ao = aorta; PA = pulmonary artery.
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The patient underwent an emergency operation. Prior to pericardiotomy, the left femoral vessels were exposed to make it possible to establish extracorporeal circulation at any time. A median sternotomy was performed. The mediastinum was seen to be filled with a huge hematoma. The pericardial sac contained blood and clots. On completion of the pericardiotomy, 3 large coronary artery aneurysms were observed: 2 were below the origin of the main pulmonary trunk; and one was exposed beneath the epicardial fat, beside the orifice of the right coronary artery (Figure 3). Each was over 3 cm in diameter. After institution of cardiopulmonary bypass, the aneurysms and the main pulmonary artery were opened under cardioplegic arrest. The orifice of the fistula was found at the sinus of Valsalva. After confirming a communication between the orifice and the aneurysm, the orifice was closed directly, and suture closure of the inflow and outflow of the aneurysm was carried out. We did not perform coronary artery bypass grafting because the aneurysms were located in a small branch of the coronary artery. The last one was beside the orifice of the right coronary artery; suture closure of the inflow of the aneurysm was performed initially, however this caused stenosis of the major trunk of the right coronary artery. Therefore, an autologous pericardial patch was used to close the entry of the aneurysm and prevent stenosis. The postoperative course was uneventful and the patient recovered well. Postoperative coronary angiography showed no aneurysm or fistula.
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Figure 3. Two coronary artery aneurysms (white arrows) were located near the main pulmonary trunk. Another one (black arrow) was exposed beneath the pericardial fat, beside the orifice of the right coronary artery. All were over 3 cm in diameter.
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DISCUSSION
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Coronary artery aneurysm is defined as dilatation that exceeds 1.5 times the width of the normal adjacent coronary artery segments. Since coronary angiography has become routine, more coronary artery aneurysms have been detected. The incidence of coronary artery aneurysm has been reported as 0.3% to 4.9%.2 The most common cause is atherosclerotic coronary artery disease, which accounts for 50% to 90% of cases.3 This case was most likely due to atherosclerosis as the patient had no history of trauma or inflammatory symptoms such as aortitis or Kawasaki disease. Most patients are asymptomatic, but some complications may occur, such as thrombosis, embolization to the distal artery with subsequent myocardial ischemia, and rupture of the involved segments. Some physicians suggest medical observation with antiplatelet and anticoagulant agents to prevent embolization to the distal coronary artery.3 On the other hand, it has been recommended that coronary aneurysms should be treated by ligation and resection, with or without concomitant coronary artery bypass grafting, to prevent distal embolization and myocardial infarction.4,5 The possibility of spontaneous rupture is usually not taken into consideration, but there are a few case reports of operations performed for rupture of a coronary aneurysm.2,3,5
The size of the aneurysm that poses a risk of spontaneous rupture has not been established. Previous reports of ruptured coronary aneurysms noted that the diameter was over 3 cm, as in our case. Therefore, when coronary angiography incidentally reveals an aneurysm over 3 cm in diameter, we suggest that it should be treated surgically before rupture occurs. Acute cardiac tamponade is often caused by acute aortic dissection, free wall rupture due to acute myocardial infarction, or a traumatic thoracic accident. This experience indicates that rupture of a coronary artery aneurysm should be considered as one of the causes of acute cardiac tamponade.
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REFERENCES
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- Daoud AS, Pankin D, Tulgan H, Florentin RA. Aneurysms of the coronary artery. Report of ten cases and review of literature. Am J Cardiol 1963;11:228–37.[Medline]
- Vijayanagar R, Shafii E, DeSantis M, Waters RS, Desai A. Surgical treatment of coronary aneurysms with and without rupture. J Thorac Cardiovasc Surg 1994;107:1532–5.[Free Full Text]
- Wan S, LeClerc JL, Vachiery JL, Vincent JL. Cardiac tamponade due to spontaneous rupture of right coronary aneurysm. Ann Thorac Surg 1996;62:575–6.[Abstract/Free Full Text]
- Berrizbeitia LD, Samuels LE. Ruptured right coronary artery aneurysm presenting as a myocardial mass. Ann Thorac Surg 2002;73:971–3.[Abstract/Free Full Text]
- Hirose H, Amano A, Yoshida S, Nagao T, Sunami H, Takahashi A, et al. Coronary artery aneurysm associated with fistula in adults: collective review and a case report. Ann Thorac Cardiovasc Surg 1999;5:258–64.[Medline]
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ABSTRACT
INTRODUCTION
