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Asian Cardiovasc Thorac Ann 1998;6:327
© 1998 Asia Publishing EXchange Pte Ltd

LETTER TO THE EDITOR

Ascending Aortic Aneurysm Presenting as Acute Myocardial Infarction in Adulthood

Hemant P Pathare, MCh, Reshma M Biniwale, MCh, Sanjay Ghotkar, MS, Jagdish Khandeparkar, MCh, Ratna A Magotra, MS

Department of Cardiovascular & Thoracic Surgery King Edward VII Memorial Hospital Parel Mumbai 400012, India
A 27-year-old hypertensive female presented with continuous severe chest pain and diaphoresis. Her electrocardiogram showed Q waves in leads II, III, and aVF. The transthoracic echocardiogram revealed minimal inferior wall hypokinesia and raised the possibility of a right ventricular mass. She was treated for the inferior wall myocardial infarction with aspirin, heparin, and intravenous nitroglycerine. She had suffered from intermittent chest pain, dry cough, and low-grade fever for over one year prior to her hospital admission. She had been erroneously diagnosed as suffering from pulmonary tuberculosis and had received 7 months of antituberculous medication. She was hemodynamically stable and her jugular venous pulse was normal. The chest radiograph showed mild cardiomegaly and a prominent ascending aorta. Magnetic resonance imaging carried out one week later showed a 8 x 8 x 10 cm mass suggestive of pseudoaneurysm of the right ventricle with thrombus, which was compressing the superior vena cava, right pulmonary artery, and the right atrium. Coronary angiography revealed extraluminal compression of the proximal right coronary artery. There was no luminal irregularity (Figure 1Go). The ascending aorta was aneurysmal with a small opening situated 5 cm above the root (Figure 2Go).



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  		Figure 1. Right coronary artery angiogram showing extraluminal compression involving the proximal course of the right coronary artery.

 


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  		Figure 2. Aortic root angiogram showing opacification of a large aneurysmal sac with an opening approximately 5 cm above the aortic valve.

 
Femorofemoral bypass was instituted and a median sternotomy was carried out. The pericardium was densely adherent to the aneurysmal sac. There was non-hemorrhagic pericardial effusion. The sac measured 12 x 10 x 8 cm and was filled with a layered thrombus. The opening into the sac was 1 cm in diameter. The arch was uninvolved. The aorta was repaired with a gelatin-impregnated knitted Dacron patch (Vascutec Ltd, Inchinnan, Scotland, UK) under deep hypothermia (18°C) and circulatory arrest. We did not graft the right coronary artery because of the excellent myocardial contractility observed during the rewarming phase. Recovery was uneventful. A two-dimensional echocardiogram carried out 3 months later revealed a good ejection fraction but the Q waves persisted in the electrocardiogram. It is extremely rare for an aneurysm of the ascending aorta not involving the aortic root to compress the right coronary artery and present as myocardial infarction, particularly at such a young age.





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Ratna A Magotra
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