Asian Cardiovasc Thorac Ann 2000;8:175-177
© 2000 Asia Publishing EXchange Pte Ltd
Giant Coronary Aneurysm Presenting as Acute Ventricular Septal Rupture
Naik Madhava Janardhan, MD, FRCS,
Lim Chong Hee, MD, FRCS,
Ding Zee Pin, MD,
Chua Yeow Leng, MD, FRCS
Department of Cardiothoracic Surgery
National Heart Centre
Singapore, Republic of Singapore
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For reprint information contact: Naik Madhava Janardhan, MD, FRCS Tel: 65 436 7598 Fax: 65 224 3632 email: mnaik{at}pacific.net.sg Department of Cardiothoracic Surgery, National Heart Centre, 17 Third Hospital Avenue, Mistri Wing, Singapore 168752, Republic of Singapore.
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Abstract
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Giant coronary aneurysm presented initially as acute ventricular septal rupture in a 65-year-old man. At surgery, aneurysms measuring more than 10 cm each were found in the right coronary and left anterior descending arteries. The right coronary artery was bypassed and the aneurysm was plicated. A 2-cm ventricular septal defect was patched. Postoperatively, the patient's condition deteriorated and he succumbed to septic shock.
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Introduction
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Giant coronary aneurysms are uncommon in routine clinical practice. They are seen incidentally during coronary angiography and may also present with various complications as is evident from isolated reports in the literature. We describe a rare case of giant coronary artery aneurysm presenting as ventricular septal rupture.
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Case Report
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A 65-year-old man was admitted to the emergency department with acute chest pain suggestive of angina, associated with pain in the interscapular area. Other than hypertension, there was no medical history of note. He was a chronic smoker but had stopped 4 years previously. Sinus tachycardia and hypotension were found and a pansystolic murmur was heard all over the precordium. An electrocardiogram showed ST-segment changes in the anterolateral leads. Chest radiography (Figure 1
) revealed severe cardiomegaly with a cardiothoracic ratio of approximately 1. Bilateral pleural effusions were also noted. Two-dimensional echocardiography demonstrated dilated cardiac chambers with global hypokinesia. There was a 2-cm ventricular septal defect in the apical part of the ventricular septum (Figure 2). A paracardiac shadow, suggestive of coronary artery aneurysm was also seen along with minimal pericardial effusion. As the general condition of the patient was deteriorating, an intraaortic balloon pump was inserted using the right femoral route. Cardiac catheterization showed giant coronary aneurysms with thrombus in the lumen. The patient underwent emergency surgery.
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Figure 2. Echocardiogram showing the ventricular septal rupture (VSR) and paracardiac shadow of the left anterior descending coronary artery (LAD) aneurysm.
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At surgery, large aneurysms measuring more than 10 cm each were seen involving both the right coronary artery and the left anterior descending coronary artery (Figure 3). The distal left artery was completely thrombosed and the whole of the anterolateral wall of the heart was congealed and dyskinetic. The right coronary artery completely obscured the right atrium, thereby precluding its cannulation for the institution of cardiopulmonary bypass. Cardiopulmonary bypass was established by cannulating the ascending aorta and the innominate vein. After going on partial bypass, the aneurysm was retracted and the right atrial appendage was cannulated to enable full cardiopulmonary bypass. Antegrade cold blood cardioplegia was given with topical cooling for myocardial protection. The right coronary artery aneurysm was opened and the clots were evacuated. As no lumen could be found in the distal right coronary artery, the posterior descending coronary artery was defined and transected to find a lumen. A vein graft was anastomosed end to end, using saphenous vein harvested from the left leg. The proximal artery was closed before it became aneurysmal and the aneurysm was plicated. The left anterior descending coronary artery was left untouched to avoid compromising the blood supply to the rest of the septum. A ventriculotomy was performed through the infarcted tissue at the apex and the 2-cm ventricular septal defect was repaired with a Dacron patch (CR Bard, Inc., Haverhill, MA, USA) using interrupted 2/0 polypropylene sutures. Fibrin glue was applied to reinforce the repair. The ventriculotomy was closed by the sandwich technique, incorporating the patch. The patient was rewarmed and slowly weaned off bypass on high doses of inotropics and intraaortic balloon pump support.
His postoperative recovery was stormy. An echocardiogram on the second postoperative day showed severely depressed myocardial function. There was a small residual defect in the ventricular septum, which was left alone as it was not hemodynamically significant. The balloon pump was removed on the 16th postoperative day. A tracheostomy was performed in the third postoperative week to improve the chances of weaning from the ventilator. Respiratory infection with gram-negative organisms and methicillin-resistant Staphylococcus aureus required treatment with high doses of antibiotics. Blood cultures grew fungi consistently, for which amphotericin B was administered. Although his fever settled and blood parameters normalized, his general condition continued to deteriorate. He developed renal failure and succumbed to septic shock 57 days after surgery.
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Discussion
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Giant coronary artery aneurysms are defined as coronary dilation exceeding 1.5 times the diameter of normal adjacent segments or the largest of the patient's normal coronary arteries.1,2 The reported incidence varies from 1.5% to 4.9%; the Coronary Artery Surgery Study (CASS) registry found an incidence of 4.9% diagnosed at coronary angiography.3 The right coronary artery is most frequently involved followed by the left anterior descending artery.1,3 Isolated case reports of left main stem involvement can also be found. Although the most common clinical feature is angina, various presentations and associations have been noted. Massive hemopericardium and cardiac tamponade due to rupture of the aneurysm have been reported.4 It is also thought to be more often associated with supravalvular aortic stenosis and abdominal aortic aneurysms.5
Four main causes of coronary aneurysms have been identified.1,2,6 Atherosclerosis is the most common cause, followed by congenital conditions. Daoud and colleagues6 found 52% were caused by atherosclerosis and 17% were congenital. Kawasaki syndrome is an important factor in this part of the world. Traumatic aneurysms have become more common with increasing percutaneous interventional procedures. Mycotic, connective tissue disorders, and metastatic tumors are among the rarer causes. Diagnosis is mostly by coronary angiography during investigations for ischemic heart disease. Although this is considered the gold standard, it may fail to reveal the aneurysm because of thrombosis. Echocardiography, particularly transesophageal, can arouse suspicion of coronary artery aneurysms when paracardiac masses are revealed.7 They may show up as solid or cystic masses with rarely, spontaneous echo contrast. Pulsatile flow may or may not be seen. Computed tomography and magnetic resonance imaging are also useful tools in the diagnosis of coronary artery aneurysms.
The treatment of coronary aneurysm depends on the mode of presentation and the symptomatic status of the patient. Medical management with antiplatelet agents and anticoagulants is considered the treatment of choice.1,2 Surgical management is reserved for the symptomatic patient and for rare complications. The argument for aggressive surgical excision or plication is based on the assumption that the aneurysm may progress to rupture. The CASS registry suggests otherwise, there being no incidence of rupture in the diagnosed group.3 However, complications due to rupture have been well reported. Other complications are enlargement, extension, and thrombosis. Various options have been proposed for surgical management. Simple bypass grafting, without dealing with the aneurysm proper, is the most popular. However, this still holds the potential for extension, thrombosis, and rupture. Hence ligation, excision, plication, and aneurysmorrhaphy have been suggested and primary cardiac transplantation was reported in a patient with Kawasaki disease involving multiple arteries.1,4,6 Our patient became a surgical candidate because of myocardial infarction resulting in ventricular septal rupture, an association hitherto unreported.
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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]
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Robertson T, Fisher L. Prognostic significance of coronary artery aneurysm and ectasia in the Coronary Artery Surgery Study (CASS) registry. In: Shulman ST, editor. Kawasaki disease. Proceedings of the Second International Kawasaki Symposium. New York: Liss, 1987:325–39.
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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]
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Yilmaz AT, Arslan M, Ozal E, Byngol H, Tatar H, Ozturk OY. Coronary aneurysm associated with adult supravalvular aortic stenosis. Ann Thorac Surg l996;62;1205–7.[Abstract/Free Full Text]
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Daoud A, Pankin D, Tulgan H, Florentin R. Aneurysms of the coronary artery. Report of ten cases and review of literature. Am J Cardiol 1963;11:228–37.[Medline]
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Quinn VJ, Baloch Z, Chandrasekaran K, Ross JJ, Karalis DG. Coronary artery aneurysm masquerading as a paracardiac mass on transesophageal echocardiography. Am Heart J 1994;127:441–3.[Medline]
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Abstract
Introduction
