Cardiovascular Disease: Student/Resident Case Report Poster - Cardiovascular Disease II |

Giant Coronary Aneurysms: Investigating a Rare Case of Cardiac Incidentaloma FREE TO VIEW

Krishna Meka, DO; Paul Adams, DO; Abigail Qin-Nelson, DO; Matthew Gaskill, DO; Brilio Mojares, MD
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St. John Macomb Hospital, Department of Internal Medicine, Warren, MI

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):104A. doi:10.1016/j.chest.2016.08.112
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SESSION TITLE: Student/Resident Case Report Poster - Cardiovascular Disease II

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Coronary artery aneurysms (CAAs) are rare (<1%) and are commonly associated with obstructive atherosclerotic disease. Giant CAAs are defined as dilatation of the coronary artery exceeding 20 mm in diameter. CAAs are associated with complications such as myocardial infarction, arrhythmia or sudden cardiac death.1

CASE PRESENTATION: A 61 year-old Albanian male with a history of hypertension presented following an episode of syncope associated with lightheadedness, diaphoresis and nausea following a bowel movement. Upon presentation, vital signs were stable and physical exam was unremarkable. Initial laboratory testing showed eosinophilia and an elevated sedimentation rate. A transthoracic echocardiogram revealed an extracardiac thick-walled loculated cyst-like structure with partial compression of the left atrium and ventricle without hemodynamic compromise (EF of 55-60%). A CT of the chest revealed three well-circumscribed vascular masses with central vascular enhancement. The largest mass (5.3cm x 5.7cm x 10cm) was noted adjacent to the left atrium and ventricle in the course of the left circumflex artery (LCx). Cardiac catheterization showed three CAAs with possible arterio-venous fistulas. Cardiac MRI showed partially thrombosed LCx and RCA aneurysms and extensive mediastinal lymphadenopathy without any RV dysplasia noted. Given the loculated structure and eosinophilia, cardiac echinococcus was considered but the echinococcus antibody was negative. Rheumatological workup including ANA, p-ANCA and c-ANCA were negative. Surgical resection and repair of the LCx and RCA aneurysm along with quadruple coronary artery bypass grafting (CABG) was performed. Mediastinal lymph node biopsy was also performed but was negative for acid-fast bacilli or fungi or histo-pathological abnormality. Two post-operative incidents of sustained monomorphic ventricular tachycardiac (VT) were noted. Subsequently, an electro-physiology study performed which revealed inducible monomorphic VT. An implantable cardioverter defibrillator was placed for secondary prevention.

DISCUSSION: Giant CAAs involving all three coronary arteries are extremely rare and have only been reported in one case report previously1. The natural course of giant CAAs is unknown given the rarity of this pathology. Size of the aneurysm is usually not an indication for surgery. However, surgical correction is often performed due to the risk of lethal complications, as these aneurysms are often thrombosed. Surgical correction may include reconstruction or arterial ligation and CABG1. Reconstruction was not feasible in this case given the markedly increased luminal diameters.

CONCLUSIONS: Giant CAAs are often discovered incidentally on routine cardiac imaging. Cardiac catheterization and MRI are crucial in guiding the pre-surgical evaluation and planning.

Reference #1: Crawley, Patricia D., et al. “Giant coronary artery aneurysms: review and update.” Texas Heart Institute Journal 41.6 (2014): 603-608.

DISCLOSURE: The following authors have nothing to disclose: Krishna Meka, Paul Adams, Abigail Qin-Nelson, Matthew Gaskill, Brilio Mojares

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