Left Anterior Descending Coronary Aneurysm
Julie-Ann S Lloyd, MS,
Eric S Weiss, MD,
Luca A Vricella, MD
Division of Cardiac Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
Luca A Vricella, MD Tel: +1 443 287 1262 Fax: +1 410 955 3809 Email: lvricella{at}jhmi.edu, Division of Cardiac Surgery, The Johns Hopkins University School of Medicine, Blalock 618, 600 N Wolfe St, Baltimore, MD 21287, USA.
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ABSTRACT
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A 19-year-old man presented with gradual onset of retrosternal chest pain and hemodynamic instability. Echocardiography and computed tomography showed substantial anterior and posterior pericardial effusion with tamponade. At surgery, a 3-cm ruptured aneurysm of the left anterior descending coronary artery was identified. It was successfully bypassed using a saphenous vein graft anastomosed to the ascending aorta.
Key Words: Aneurysm • Ruptured • Coronary Vessel Anomalies • Pericardial Effusion
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INTRODUCTION
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Coronary artery aneurysms (CAA) are an uncommon anomaly, with a reported incidence of 0.15%–4.9%; only 2.2% of CAA affect the left anterior descending coronary artery (LAD).1 Although infrequent, CAAs can have devastating consequences if not accurately diagnosed and appropriately managed. We describe a case of ruptured LAD aneurysm leading to cardiac tamponade, which was successfully repaired. This account might raise awareness of this rare but potentially deadly disorder.
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CASE REPORT
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A 19-year-old man, whose past medical history was remarkable only for a bout of dengue fever 10 years earlier, presented with gradual onset of retrosternal chest pain with radiation to the left shoulder. Although his discomfort occurred over 3 weeks, it had worsened 2 days prior to admission. On physical examination, heart sounds were distant, heart rate was >120 beats per minute, systolic blood pressure was 60 mm Hg, and prominent jugular venous distension was noted. Echocardiography revealed a large pericardial effusion with tamponade. After resuscitation, the patient was stabilized and transferred in emergency status to our tertiary care institution. Repeat echocardiography confirmed substantial anterior and posterior pericardial effusion, measuring 3 cm in largest diameter. Computed tomography defined the location of the effusion and helped plan the surgical evacuation (Figure 1
). A subxiphoid pericardial window was created and converted to a full sternotomy after finding a large amount of clotted blood within the pericardium. Removal of a thrombus from around the obtuse margin resulted in massive arterial bleeding, requiring emergency institution of cardiopulmonary bypass via the femoral vessels. Peripheral cannulation was rapidly performed because of difficulty in controlling massive bleeding from the unroofed aneurysm and the huge intramediastinal hematoma. Following cardioplegic arrest and debridement of clots and fibrinous material, a 3-cm ruptured aneurysm of the LAD was identified at the level of the first diagonal branch. The LAD could not be reconstructed so it was ligated proximally and distally to the aneurysm, and bypassed with an autologous saphenous vein graft anastomosed to the ascending aorta. The postoperative course was uncomplicated, and the patient was discharged on the 7th postoperative day. He was well 24 months later.
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Figure 1. A 64-slice axial computed tomogram of the chest, demonstrating a left anterior descending coronary artery aneurysm, measuring 31 mm in the largest diameter (arrow). It is easy to see how the aneurysm could be confused with the right ventricular outflow tract because of its smooth contrast enhancement and location.
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DISCUSSION
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CAA is defined as an abnormal dilatation of the coronary artery>one and a half times the diameter of the largest native coronary vessel. Most coronary aneurysms involve the right coronary circulation. Syed and colleagues1 reported that when CAAs involve the left coronary system, aneurysm formation affects the left circumflex artery in 57.5% of cases and the LAD in only 39.4%. There are many reports of left main CAAs, but our literature review identified only 3 cases of ruptured LAD aneurysms, 2 of which underwent surgical repair.3–5 Early diagnosis after rupture is crucial in achieving a good outcome.
Causes of CAA include atherosclerosis, Kawasaki disease, connective tissue disorders, bacterial infections, and trauma. With increased use of cardiac catheterization, iatrogenic causes are becoming more prevalent.1 The number of arteries affected varies according to etiology. Atherosclerotic aneurysms can involve both right and left systems simultaneously, whereas congenital and traumatic CAAs usually occur in isolation. The exact etiology of our patient’s CAA is unknown; there are no reports of an association with dengue fever.6 Although the gold standard for diagnosis of CAA is angiography, computed tomography is utilized increasingly. In this case, we were misled by the computed tomography scan. Although the large pericardial effusion was evident, the contrast-enhanced aneurysm (arrow, Figure 1
) was easily confused with the pulmonary artery trunk by both surgeons and radiologists.
The natural history of CAA is unknown; however, CAA-associated complications range from thromboembolism and stroke to angina, myocardial infarction, and rupture.2 A 1997 study reviewing CAAs reported that 70% of patients developed thrombus, and 40% had associated severe wall-motion abnormalities.1 There is scarce consensus on whether or when to intervene surgically. The optimal therapy depends on the size and complexity of the aneurysm. A small asymptomatic aneurysm might require close observation only, whereas surgery is necessary for larger CAAs to prevent thromboembolic events and/or free rupture. Patients should receive anticoagulation or antiplatelet therapy concomitantly. This case highlights the importance of accurate diagnosis and appropriate vigilance in patients with this condition.
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REFERENCES
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- Syed M, Lesch M. Coronary artery aneurysm: a review. Prog Cardiovasc Dis 1997;40:77–84.[Medline]
- Pinheiro BB, Fagundes WV, Gusmão CA, Lima AM, Santos LH, Vieira GB. Surgical management of a giant left main coronary artery aneurysm. J Thorac Cardiovasc Surg 2004;128:751–2.[Free Full Text]
- Anania A, Trapani M, Striglia E, Sambuco A, Longato L, Tarocco RP. Giant coronary artery aneurysm in association with systemic arterial ectasia. A case report. Minerva Cardioangiol 2006;54:169–72.[Medline]
- Yamaki F, Nakajima M, Hirayama T, Kume S. A case report of surgical treatment of ruptured coronary artery aneurysm. Nippon Kyobu Geka Gakkai Zasshi 1993;41:2229–33.[Medline]
- Oka Y, Yoshida N, Nakamura T, Hara Y, Ishikura Y. A case of coronary-pulmonary artery fistula with saccular aneurysm. Kokyu To Junkan 1991;39:487–90.[Medline]
- Wali JP, Biswas A, Chandra S, Malhotra A, Aggarwal P, Handa R, et al. Cardiac involvement in dengue haemorrhagic fever. Int J Cardiol 1998;64:31–6.[Medline]
Asian Cardiovasc Thorac Ann 2009;
17:82-83
© 2009 by SAGE Publications
DOI: 10.1177/0218492309102537
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ABSTRACT
INTRODUCTION
