Abstract 2112: Silent Killer: The Rare And Potentially Lethal Right Coronary Artery Aneurysm

BackgroundGiant coronary artery aneurysms are rare conditions with potentially devastating consequences. We report a case of the largest documented giant right coronary artery (RCA) aneurysm to date.Case presentationA 57-year-old male patient visited our outpatient clinic for abdominal pain and exertional dyspnea. Computed tomography identified a 10.2 × 9.8 cm RCA aneurysm with RCA pressure waves were similar to aortic pressures. After discussion by the cardiac team, elective resection with ligation of the proximal and distal ends of the RCA was performed due to the presence of adequate collaterals.ConclusionWe highlight the challenges related to the management of patients presenting with giant coronary artery aneurysms. Optimal management strategies and outcomes for such rare cardiovascular conditions implies the need for standardised management guidelines.

Resection of Giant Coronary Artery Aneurysms in a Takayasu's Arteritis Patient

Giant Thrombotic Right Coronary Aneurysm in an Infant with Undiagnosed Incomplete Kawasaki Disease and Rapidly Progressive Cardiovascular Collapse

<p>Coronary artery aneurysm (CAA) is a rare entity, defined as localized dilation that exceeds the normal vessel diameter by a factor of 1.5. A giant CAA is described as a very large dilation, when diameter exceeds 20 mm. CAA has a preva-lence of 0.02% [Markis 1976]. Different factors may lead to CAA formation, including Kawasaki disease, atherosclerosis, congenital malformations, autoimmune and infectious disor-ders, and percutaneous interventions [Hartnell 1985]. Man-agement of these patients remains controversial due to a lack of data from large series studies.</p><p>We reported a case of a young female patient, who pre-sented with an acute inferior infarction and was diagnosed with a giant right coronary artery (RCA) aneurysm. She underwent aneurysmectomy and revascularization on a beat-ing heart through a right lateral thoracotomy. Due to the minimally invasive nature of this procedure, the patient was able to recover quickly without substantial cosmetic changes.</p>

Giant right coronary artery (RCA) aneurysm is a rare coronary artery pathology. We describe a 45-year-old gentleman who presented with unstable angina of recent onset. Diagnostic workup including chest computed tomography angiography and left heart catheterization demonstrated three-vessel coronary artery disease with giant proximal RCA aneurysm. In the view of the severity of the coronary artery disease and the risk of rupture associated with the giant RCA aneurysm and the clinical presentation, the patient was successfully treated by coronary artery bypass surgery. During this procedure, the RCA aneurysm was ligated at both inflow and outflow. The patient recovered well and was discharged home.

Introduction: Coronary artery aneurysm (CAA) is a vessel dilation exceeding 1.5 times adjacent normal segments. We present a case of massive right coronary artery (RCA) aneurysm complicated by ST elevation (STE) myocardial infarction. Case Summary: An 87-year-old female with no significant medical history presented with chest pain. Vitals signs and physical exam were normal. A 12 lead EKG demonstrated STE in inferior leads. Coronary angiography revealed a large aneurysm of the RCA throughout its course (max diameter 20 mm) with TIMI I flow. In the mid RCA, there was a long filling defect with irregular borders consistent with a congealed, organized layered thrombus causing 90% stenosis. Percutaneous coronary intervention (PCI) was not pursued due severe aneurysmal dilation and risk for embolization. The proximal to mid left anterior descending artery (LAD) and abdominal aorta were also aneurysmal. The patient was deemed not to be a surgical candidate after a heart team discussion (STS risk of morbidity or mortality = 12.6%). Left ventricular ejection fraction was 60%. Chest pain resolved and patient was discharged on indefinite anticoagulation and antiplatelet therapy. Discussion: Giant CAAs are rare, with an incidence of 0.02%. Causes include atherosclerosis, Takayasu arteritis, Kawasaki disease, or congenital defects. Although mostly incidental, CAA can be complicated by thrombosis, embolization, fistulation, rupture, arrhythmia, or sudden death. Our patient had an acute RCA thrombus due to stasis and turbulent blood flow in the aneurysm. Localized CAA are treated with surgery or percutaneous coiling or stenting. However, PCI was not feasible in our patient due to risk of embolization and difficultly with stent apposition in the setting of a diffuse, giant-sized aneurysm. Conclusion: CAAs are rare but may cause grave complications. A heart team discussion is essential to guide appropriate medical, percutaneous, or surgical treatment based on vessel anatomy.

Patient: Male, 64-year-oldFinal Diagnosis: Huge coronary aneurysmSymptoms: Chest discomfort • dyspneaMedication: Losar 25 mg twice daily • Amlodipine 5 mg twice daily • Aspirin 80 mg daily • Atorovastatin 20 mg daily • Pantaprazole 20 mg dailyClinical Procedure: Coronary artery bypass graft surgerySpecialty: Cardiac Surgery • CardiologyObjective:Rare diseaseBackground:Giant coronary artery aneurysm (GCAA) is a rare disease, with an incidence of 0.02% in the general population. GCAA is defined as when the diameter of the coronary artery is more than 4 times the adjacent part or more than 8 mm. There are several causes of GCAA, with atherosclerosis being the most common. Patients with giant coronary artery aneurysms can be asymptomatic or develop chest pain, dyspnea, and palpitations. Complications of GCCA include myocardial infarction, thrombosis, and sudden death, so early treatment is necessary to prevent mortality. There is no standard surgical approach for a giant coronary artery aneurysm.Case Report:A 64-year-old man with hypertension, opium addiction, morbid obesity (body weight 151 kg and BMI 46), and benign prostate hyperplasia presented with a giant coronary aneurysm in coronary angiography. The patient underwent cardiac surgery, and a 42-mm coronary aneurysm was detected. The aneurysm had many orifices that opened to the left main coronary artery, left circumflex artery, LAD, the diagonal branch of the LAD, and the septal branch of the LAD. Aneurysmectomy and coronary artery bypass graft were successfully performed.Conclusions:Giant coronary artery aneurysms are rare. Patients with giant coronary artery aneurysms may experience sudden death due to myocardial infarction and other cardiovascular complications due to ischemia. Because it is rare, there is no standard surgical approach for a giant coronary artery aneurysm. Further studies need to focus on standardized surgical management of patients with giant coronary artery aneurysms.

Objective: To summarize the clinical features, middle-and long-term prognosis of Kawasaki disease (KD) with giant coronary artery aneurysm (GCAA). Methods: In this retrospective cohort study, a cross-sectional analysis was conducted on 101 KD children with GCAA in the KD with GCAA database established by Beijing Children's Hospital, Capital Medical University in 2004. GCAA was diagnosed as coronary artery absolute lumen diameter ≥8.0 mm. All patients were followed up regularly. The endpoint was the time of last follow-up or the death time. T test or χ2 test was used for comparison between groups. Results: A total of 101 KD children with GCAA were enrolled, including 82 males (81.2%) and 19 females (18.8%). The age of disease onset was 2.5 (1.0, 4.5) years. The follow-up duration was 4.5 (2.7, 7.5) years, with a longest of 19 years. All children received routine treatment with aspirin and warfarin, and clopidogrel was added in severe cases. At the end of follow-up, 13 cases (12.9%) had cardiac enlargement, 11 cases (10.9%) developed heart failure, 13 cases (12.9%) experienced myocardial infarction, 2 cases (2.0%) underwent coronary artery bypass graft and 6 cases (5.9%) died. A total of 170 coronary arteries were involved, including 24 (14.1%) GCAAs on the main trunk of left coronary artery, 10 (5.9%) GCAAs on left circumflex, 57 (33.5%) GCAAs on left anterior descending, 78 (45.9%) GCAAs on the middle segments of right coronary artery, and 1 (0.6%) GCAA in the distal segments of right coronary artery. Eleven cases (10.9%) recovered with the coronary artery absolute lumen diameter of all GCAAs below 4.0 mm. Among 170 branches with GCAAs, 28 (16.5%) regressed below 4.0 mm. No significant difference was found in the regression rates between right and left GCAA (18.7% (17/91) vs. 13.9% (11/79), χ²=2.473, P=0.116). There was no statistically significant difference in retraction between unilateral GCAA and bilateral GCAA (16.1% (9/56) vs. 4.4% (2/45), χ2=2.381, P=0.123). Conclusions: GCAA of KD occurred more common in the middle segments of right and left anterior descending coronary arteries. The incidence of adverse cardiac events and the mortality rate in children with GCAA complicated with KD was high. Their long-term prognosis was poor.

Successful Revascularization of Multiple Coronary Artery Aneurysms Using a Combination of Surgical Strategies

Objective To observe the mid- and long-term changes of giant coronary artery aneurysm(GCAA) caused by Kawasaki disease(KD) and to provide preventive basis for cardiac accidents of KD-affected adolescents. Methods Twelve cases of KD with GCAA [10 boys, 2 girls; 1-10 years old; mean age: (4.05±2.50) years old] were followed up by coronary angiography (CAG), echocardiography and electrocardiogram for 2-10 years to and the changes of the coronary artery lesion were analyzed. Results The findings showed that 2 cases were single coronary artery aneurysm and 10 cases had multiple coronary artery aneurysms on both sides by echocardiography.Among them 8 cases showed segmental stenosis in the right coronary artery with varying degrees by coronary angiography, including 3 cases with coronary recanalization after right coronary artery complete occlusion, 4 cases with segmental local stenosis, and 1 case with thrombotic occlusion and tufted neovascularization.And in 9 cases of coronary artery aneurysms were still present after treatment, and among them the blood flow filling in 4 cases was slowing down in the left anterior descending arteries.Only 1 case with coronary artery aneurysms on both sides became expanded mildly, without stenosis or other lesions.In this observation, all of the cases had no symptoms or any activity limitation.One case was found pathologic Q wave and the other 11 cases left normal by resting electrocardiogram.The results of resting electrocardiogram in 11 cases were normal by pharmacologic stress electrocardiogram except that 1 case showed multi-lead S-T segment depression and T wave flat.Compared with coronary angiography in the same period, 12 cases showed proximal morphological changes in coronary artery and 5 cases with wall motion abnormalities by echocardiography.This study showed that echocardiography was not sensitive enough for mid- and distal-stenosis examination because it failed to provide any useful information for 4 cases affected by segmental stenosis and neovascularization. Conclusions The GCAA caused by KD will be lasting for a long time after acute stage, including persisting GCAA, recovering GCAA, occlusion, stenosis and neovascularization.The sensitivity of echocardiography and electrocardiogram are not enough to find coronary morphology and function of KD sequelae damages.CAG is important for follow-up observations of KD with GCAA. Key words: Kawasaki disease; Giant coronary artery aneurysm; Coronary angiography; Follow-up

Giant Aneurysm of the Left Atrial Branch of the Left Circumflex Artery With Fistula

Coronary artery aneurysms (CAAs) due to an immunoglobulin G4 (IgG4)-related disease (IgG4-RD) are relatively rare, and there is no consensus on the choice of treatment method. In the present study, we report the results of the surgical treatment for multiple giant CAAs caused by IgG4-RD. A 71-year-old man was diagnosed with severe aortic regurgitation and CAAs. A blood test showed high IgG4 levels, and computed tomography revealed four giant coronary artery aneurysms: two in the right coronary artery (RCA) (proximal RCA and posterior descending artery (PDA)), one in the left anterior descending (LAD), and one in the diagonal branch (Dx). We planned aortic valve replacement, coronary aneurysm resection, and coronary artery bypass grafting (CABG). After finishing aortic valve replacement, the CAAs in proximal RCA, LAD, and Dx were resected. The proximal and distal tracts of the aneurysm were closed with a pericardial bovine patch and ligation. However, since the distal PDA was too calcified to be anastomosed, and the PDA aneurysm was smaller than the others, it was decided to leave the PDA aneurysm. The anastomoses of SVG-RCA and Dx, as well as the left internal thoracic artery to LAD, were performed. Histopathological examination of the aneurysm wall showed a high IgG4-positive cell/IgG-positive cell ratio, and a diagnosis of IgG4-RD was made. In the treatment of CAAs due to IgG4-RD, it is essential to select a procedure that takes into account the size, location, and nature of the aneurysm, and comorbidities. To ensure resection of the aneurysm and blockade of blood flow, closure of the inflow and outflow tracts with a pericardial bovine patch and CABG are effective.

We report the case of a 66-year-old man with a left anterior descending (LAD) coronary artery aneurysm. Cigarette smoking and hepatitis C virus infection were in his clinical history. Coronary angiography performed in 2002 showed a LAD aneurysm, a 50% stenosis of the right coronary artery, and a 30% stenosis of the left main artery (Figure 1, a through c). The ECG in 2002 was normal (Figure 2b i ). In 2002, the patient underwent successful Jomed polytetrafluoroethylene (PTFE)-coated stenting (3.0×20 mm) to cover the aneurysm (Figure 1d). After stenting, the patient was discharged on ticlopidine 250 mg/d for 1 year, aspirin 100 mg/d, metoprolol 25 mg/d, and transdermal nitrates. Figure 1. LAD …

Giant left coronary artery aneurysms: Review of the literature and report of a rare case diagnosed by transthoracic echocardiography

Giant coronary artery aneurysms are an infrequent finding. They are typically discovered incidentally, rarely presenting with any symptoms. We present the case of a 72-year-old gentleman who presented with an ST elevated myocardial infarction. On investigation, the gentleman was found to have a giant right coronary artery aneurysm which was partially filled with a fresh thrombus. The thrombus occluded the RCA, triggering the myocardial infarction which leads to this gentleman’s presentation to a tertiary cardiac centre. The gentleman underwent a successful resection of the aneurysm and coronary artery bypass graft over the RCA lesion with a saphenous vein conduit. This gentleman has since been discharged from hospital after an uncomplicated postoperative course.