Spontaneous Rupture of a Left Main Coronary Artery Aneurysm

Abstract

We report a case of left main coronary artery (LMCA) aneurysm rupture while the patient was hospitalized and immediately after imaging with 2 noninvasive cardiac modalities. An 85-year-old man with history of atrial fibrillation, prostate cancer, hypertension, and hyperlipidemia presented with sudden lightheadedness, chest pressure, and junctional bradycardia (heart rate, 40 bpm). He was admitted to a telemetry bed; warfarin was held and unfractionated heparin was administered. The following day, heparin was held because of supratherapeutic-activated partial thromboplastin times. Transthoracic echocardiogram was performed demonstrating normal ejection fraction, normal wall motion, mild aortic root dilatation, and no pericardial effusion; nothing unusual about the coronary anatomy was noted. Computed tomography coronary angiography to evaluate for coronary artery disease and computed tomography of the chest with contrast to evaluate for pulmonary embolism were performed shortly afterward. Preliminary reports for these studies indicated no pulmonary embolus, mildly aneurysmal thoracic aorta, no thrombus in the left atrial appendage, and <50% stenosis of the left anterior descending ostium. A subsequent final interpretation reported an aneurysmal LMCA (Figure 1). Shortly after returning to his room, the patient developed sudden, severe hypotension and left chest discomfort. Intravenous fluids and vasopressors were administered with minimal effect. Urgent repeat transthoracic ECG showed a new, large pericardial effusion with tamponade (Figure 2). Because of refractory hypotension, emergency pericardiocentesis was arranged. Figure 1. Large left main coronary artery (LCMA) aneurysm on coronary computed tomography angiogram. …