Asian Cardiovasc Thorac Ann 2001;9:215-217
© 2001 Asia Publishing EXchange Pte Ltd
Surgical Treatment of Giant Coronary Artery Aneurysm
Wu Qing Yu, MD,
Li Dian Yuan, MD,
Hu Sheng Shou, MD,
Pan Shi Wei, MD,
Qi Shi Tao, MD
|
Department of Cardiovascular Surgery Cardiovascular Institute and Fu Wai Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing, People's Republic of China
|
|
|
For reprint information contact: Wu Qing Yu, MD Tel: 86 10 6831 4466 Fax: 86 10 6833 2376 email: wuqingyu{at}public.bta.net.cn Department of Cardiovascular Surgery, Cardiovascular Institute and Fu Wai Hospital, 167 Beilishi Road, Xicheng Region, Beijing 100037, People's Republic of China.
|
 |
Abstract
|
|---|
A 39-year-old man and a 38-year-old woman were diagnosed to have giant coronary artery aneurysm with a fistula to the left ventricle. Coincidental aortic valve incompetence was also present in the man. The manifestations and successful surgical management of this rare pathology are described.
|
INTRODUCTION
|
|---|
A coronary artery fistula is uncommon, especially one that drains into the left ventricle (LV).1–3 Coronary artery aneurysms are also rare, so the presence of a coronary artery aneurysm with a fistula into the LV is extremely unusual.
|
CASE REPORTS
|
|---|
PATIENT 1
A 39-year-old man was admitted on an emergency basis with acute congestive heart failure. Physical examination revealed a blood pressure of 130/80 mm Hg and an arrhythmic heart rate of 70 beats.min–1. A grade 3/6 systolic murmur could be heard along the left 4th intercostal space, and there was a grade 3/6 blowing diastolic murmur in the aortic valve region. An electrocardiogram showed atrial fibrillation and left ventricular hypertrophy. Chest radiography indicated a very large mass adjacent to the right heart border, and a cardiothoracic ratio of 0.68. Echocardiography and ultrafast computed tomography (UFCT) revealed a large aneurysm of the right coronary artery (RCA), 30 mm proximal to the RCA ostium, measuring 121 x 138 mm. The aneurysm drained into the LV through the left inferoposterior wall and was so large that it compressed both the right atrium and right ventricle, restricting inflow to the right ventricle (Figure 1
). Coronary arteriography and an aortogram confirmed the presence of a giant RCA aneurysm that communicated directly with the LV. The fistula was located in the posterior of the right atrioventricular groove and measured 20 mm in diameter. There was no anomaly of the RCA distal to the lesion.
View larger version (172K):
[in this window]
[in a new window]
|
Figure 1. Ultrafast computed tomography in patient no. 1, revealing a giant right coronary aneurysm with a diameter of 138 mm.
|
|
At operation, an aneurysm of the RCA measuring 150 x 160 x 150 mm was found before the right atrium. The ostium of the RCA was 20 mm in diameter. Exploration from the LV indicated that the distal part of the aneurysm communicated with the LV and the diameter of the mouth of the fistula was 20 mm (Figure 2). The fistula was located at the level of the crotch of the posterior descending branch of the RCA and the posterior left ventricular branch of the RCA; both branches were normal. In addition, the annulus of the aortic valve was dilated, the posterior leaflet had prolapsed, the edges of the valve were thickened, and there was severe regurgitation. Femoral cannulation was used for cardiopulmonary bypass (CPB) because the RCA aneurysm was too large to allow institution of standard CPB. The ascending aorta was interrupted and opened, and cardioplegic solution was delivered directly into the coronary arteries 4 times during circulatory arrest. Under moderate hypothermia, the aneurysm was resected and interrupted sutures were inserted for closure of the fistula, while 4/0 polypropylene running sutures were used to repair the large defect in the aortic wall with a 2 x 2.5-cm Dacron patch and to close the right coronary ostium. The posterior descending and left ventricular posterior branches of the RCA were bypassed with a Y-shaped saphenous vein graft. A size 29-mm St. Jude Medical mechanical valve (St. Jude Medical, St. Paul, MN, USA) was used to replace the aortic valve. The circulatory arrest time was 172 minutes and the CPB time was 207 minutes; the total cardioplegic solution infused was 4,980 mL. After follow-up of 9 months, the patient was doing well. Echocardiography and UFCT demonstrated that the giant RCA aneurysm had disappeared (Figure 3).
View larger version (145K):
[in this window]
[in a new window]
|
Figure 2. Through the incision in the giant right coronary aneurysm, it could be demonstrated that the aneurysm communicated with the left ventricle. The right-angled forceps exploring from the left ventricle could be seen within the fistula. The diameter of the fistula was 20 mm.
|
|
View larger version (125K):
[in this window]
[in a new window]
|
Figure 3. Postoperative ultrafast computed tomography of patient no. 1 showed the giant right coronary aneurysm was replaced by a saphenous vein graft (black arrow).
|
|
PATIENT 2
A 38-year-old woman with a 10-year history of palpitations was referred for congestive heart failure. Her blood pressure was 100/50 mm Hg and her heart rate was 84 beats.;min–1. A grade 3/6 murmur could be heard over the 2nd to 4th left intercostal spaces. An electrocardiogram demonstrated left ventricular hypertrophy. Chest radio-graphy showed a cardiothoracic ratio of 0.66 and a giant mass in the left middle mediastinum (Figure 4). Echo-cardiography and UFCT revealed a large aneurysm of the left coronary artery, measuring 92 x 130 mm. The aneurysm compressed the main pulmonary artery and caused pulmonary artery obstruction. The left main coronary artery, proximal left anterior descending coronary artery, and the circumflex artery were all enlarged and involved in the structure of the aneurysm. The aneurysm was located along the anterior wall of the LV and drained into the LV through the interventricular septum, near the cardiac apex. An area of the interventricular septum, measuring 13 x 26 mm, formed part of an aneurysmal compartment. Coronary arteriography confirmed a giant aneurysm of the left coronary artery (100 x 60 mm), which communicated directly with the LV (Figure 5). There were no anomalies of the RCA or left circumflex coronary artery distal to the lesion.
View larger version (128K):
[in this window]
[in a new window]
|
Figure 4. Chest radiograph of patient no. 2, showing a giant mass in the left middle mediastinum; the cardiothoracic ratio was 0.66.
|
|
View larger version (95K):
[in this window]
[in a new window]
|
Figure 5. Coronary angiogram of patient no. 2, revealing a giant left coronary aneurysm with a diameter of 100 mm.
|
|
At operation, the left coronary artery aneurysm was found to measure 130 x 140 x 135 mm. It originated from the left main coronary artery, involved the anterior descending and circumflex branches, and dilated to form an interventricular septal compartment at the first septal branch of the anterior descending artery. The aneurysm communicated with the LV through the interventricular septum at the bottom of the LV, and the mouth of the fistula was 5 mm in diameter. The RCA and aortic valve were normal. Under routine CPB with moderate hypo-thermia, the aneurysm was resected and the fistula was closed with interrupted sutures. A 3/0 polypropylene running suture was used to repair the wall of the aorta directly. The left anterior descending artery was bypassed with a left internal mammary artery graft. The marginal branch and the first and second diagonal branches were bypassed with saphenous vein grafts. The circulatory arrest time was 146 minutes and the CPB time was 205 minutes. Pathological evaluation of the lesion demon-strated that the aneurysm was caused by a congenital malformation. The patient recovered fully and was discharged. After 6 months of follow-up, she was asymptomatic, and echocardiography revealed that the giant coronary artery aneurysm and the shunt between the aneurysm and the LV had disappeared.
|
DISCUSSION
|
|---|
The incidence of coronary artery fistula ranges from 0.27% to 0.40%, and only 8% of fistulas drain into the LV.1–3 Such fistulas are congenital in 64% of cases; 36% are acquired secondary to various procedures such as percu-taneous transluminal coronary angioplasty, permanent ventricular pacing lead insertion, or cardiac surgery.3 The majority of patients (59%) remain asymptomatic.3 In cases treated surgically, direct ligation was used in 76%, CPB in 23%, and hypothermia in 1%.4 Coronary artery aneurysm is generally defined as dilatation to more than 1.5 times the diameter of the adjacent normal segment of the largest coronary artery.5 The incidence of aneurysms of the coronary arteries is estimated to be 1.5% at necropsy or coronary arteriography.6
The most common cause of coronary artery aneurysm seems to be atherosclerosis, but other conditions have been implicated including congenital malformations, bacterial infection, vasculitis, Kawasaki disease, and neoplasm.7 Reported complications include thrombosis and distal embolization, rupture, and vasospasm. The natural history and prognosis remain obscure. Although an isolated coronary artery fistula can be diagnosed conclusively by echocardiography, additional coronary arteriography is necessary in patients with a combined giant coronary aneurysm. UFCT and serial 3-dimensional imaging can define the shape and size of a coronary aneurysm and its relationship with the cardiac chambers.
The coronary aneurysms reported here seem to be the largest documented in the literature. Congenital malfor-mation was the most likely cause of the giant aneurysms and fistulas in both patients. Unlike cases of coronary artery fistula without aneurysm, these patients were symptomatic and at high risk because the massive size of their aneurysms posed the danger of imminent rupture. Thus, CPB with moderate hypothermia was employed to resect the aneurysms and close the fistulas without delay.
|
REFERENCES
|
|---|
-
Chen CC, Hwang B, Husing MC, Chiang BN, Meng, LC, Wang DJ, et al. Recognition of coronary fistula by Doppler two-dimensional echocardiography. Am J Cardiol 1984;53:392–4.[Medline]
-
McNamara JJ, Gross RE. Congenital coronary artery fistula. Surgery 1969;65:59–69.[Medline]
-
Sunder KRS, Balakrishnan KG, Tharakan JA, Titus T, Pillai VRK, Francis B, et al. Coronary artery fistula in children and adults: a review of 25 cases with long-term observations. Int J Cardiol 1997;58:47–53.[Medline]
-
Said SA, el Gamal MI, van der Werf T. Coronary arteriovenous fistulas: collective review and management of six new cases — changing etiology, presentation, and treatment strategy. Clin Cardiol l997;20:748–52.
-
Swaye PS, Fisher LD, Litwin P, Vignole PA, Judkins MP, Kemp HG, et al. Aneurysmal coronary artery disease. Circulation 1983;67:134–5.[Abstract/Free Full Text]
-
Wenger NK. Nonatherosclerotic causes of myocardial ischemia and necrosis. In: Hurst JW, editor. Hurst's the heart. 4th ed. New York: McGraw-Hill, 1978:1345–62.
-
John LC, Hornick P, Davies DW, Banim SO, Rees GM. The role of surgery in the management of solitary coronary artery aneurysm. Eur J Cardio-thorac Surg 1991;5:440–1.[Abstract]
This article has been cited by other articles:
|
|
|
|
 
D. Li, Q. Wu, L. Sun, Y. Song, W. Wang, S. Pan, G. Luo, Y. Liu, Z. Qi, T. Tao, et al.
Surgical treatment of giant coronary artery aneurysm
J. Thorac. Cardiovasc. Surg.,
September 1, 2005;
130(3):
817 - 821.
[Abstract]
[Full Text]
[PDF]
|
|
|
TOP
Abstract
INTRODUCTION
