Coronary artery aneurysm is dilatation greater than 1.5 times an adjacent normal coronary artery. We report a case of an unusually large right coronary artery aneurysm (RCA) presenting with chest pain.
A 61 year old male with hypertension and hyperlipidimia had persistent retrosternal and epigastric pain over several months. It had no relation to exertion. His blood pressure was 194/115 mm Hg. The remainder of the physical examination was unremarkable. A 12-lead electrocardiogram revealed normal sinus rhythm with left ventricular hypertrophy. On chest x-ray, a hiatal hernia was suspected but endoscopy was normal. A chest CT and MRI suggested sinus of valsalva aneurysm. Coronary angiography revealed diffuse ectasia in the left coronary artery. The right coronary artery could not be engaged, but non-selective injection of the right coronary artery suggested a large aneurysm . It was better visualized by a trans-esophageal echocardiography (figure 1a,1b). An aneurysm of the right coronary artery measuring 7 x 11cm (figure 2) was resected with saphaneous vein bypass of the distal right coronary artery. Pathologic changes of the resected right coronary artery were most consistent with cystic medial necrosis. At 6 months follow-up, he has resumed most of his customary activities prior to surgery. His chest pain has resolved initially, but persistent retrosternal sharp pain, somewhat different from his presenting symptoms emerged at 6 months follow-up.
We reported the case of the largest (11 cm x 7cm) coronary artery aneurysm described. Nawwar et al. reported a 6 cm aneurysm of the LAD (1) presenting with stroke, Banarjee et al. reported a 5.3 cm aneurysm of the RCA presenting with acute myocardial infarction (2), and Pinheiro et al described a giant aneurysm of left main aneurysm 5.6 cm in diameter (3). The natural history and prognosis of coronary aneurysm has not been delineated. Indeed, criteria for diagnosis have not been established, perhaps this explains why the reported incidence on angiography varies between 0.2% and 4.9% in patients undergoing coronary angiography. There is male predominance and a predilection for the right coronary artery, with left anterior descending artery involvement less common. The most common etiology reported is atherosclerosis accounting for 50%, followed by congenital origin and Kawasaki’s disease (4). Other etiologies include arteritis, mycotic infections, connective tissue disorders, trauma and metastatic tumor. Coronary aneurysms have also been associated with percutaneous transluminal coronary angioplasty espeically after dissection, and with angioplasty using an oversized balloon or directional atherectomy. There are no clinical features of coronary artery aneurysm. Most patients are asymptomatic. Myocardial infarction, thromboemboli, and sudden cardiac death with acute rupture have been reported in association of coronary artery aneurysm. As for our patient, was his presenting chest pain a clinical manifestation of the large coronary aneurysm? And, is his recurrent chest pain a manifestation of a similar disease? This will be clarified by the follow-up cardiac imaging studies plan.
Coronary artery aneurysm should be considered in the differential diagnosis of chest pain. The size can be very large and its diagnosis may require more than one imaging modality.
Simon Topalian, None.