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CARDIAC SURGERY _____________________________________________________
Giant Coronary Aneurysms with Associated Aneurysm of the Ascending Aorta Daniel R. Obaid, Ph.D., M.R.C.P., Aprim Youhana, F.R.C.S., and Alexander J. Chase, Ph.D., F.R.C.P. Morriston Cardiac Centre, Abertawe Bro Morgannwg University NHS Trust, Swansea, UK doi: 10.1111/jocs.12206 (J Card Surg 2013;28:567–568)
A 79-year-old male with a 3-month history of progressive dysphagia presented with an antero-septal myocardial infarction. Chest radiograph revealed a widened mediastinum (Fig. 1A). Contrast-enhanced computed tomography (CT) revealed a large aneurysm
of the ascending aorta (10.3 9.1 cm; Fig. 1B). The CT scan also demonstrated giant coronary aneurysms in the proximal left anterior descending artery (LAD; 3.8 cm 4.1 cm), the left circumflex artery (LCX; 3.8 cm), and the proximal right coronary artery
Figure 1. (A) Chest radiograph with widened mediastinum. (B) Chest CT demonstrating aneurysmal ascending aorta (AscAo) and normal calibre descending aorta (DesAo).
Conflict of interest: The authors acknowledge no conflict of interest in the submission. Address for correspondence: Dr. Daniel R. Obaid, Ph.D., M.R.C.P., Department of Cardiology, Morriston Hospital, Swansea SA6 6NL, UK. Fax: þ44-1792-703318; e-mail: [email protected]
(RCA; 7.8 5.7 cm; Fig. 2A). Coronary angiography revealed a giant aneurysm in the LAD, a tight stenosis in the proximal LCX proceeded by a giant aneurysm and a complete occlusion in the proximal RCA (Fig. 2B and C). Pre-operative left ventricular function was poor (ejection fraction 10–20%).
OBAID, ET AL. GIANT CORONARY ANEURYSMS WITH ASSOCIATED ANEURYSM
J CARD SURG 2013;28:567–568
Figure 2. (A) Chest CT demonstrating calcification of the left main stem (LMS) (black arrow) and aneurysmal dilatation of all three major epicardial coronary arteries (Ao-Aorta). (B and C) Invasive coronary angiogram demonstrating a tight stenosis in proximal LCX (white arrow) with proceeding aneurysm, aneurysm in LAD with TIMI 1 distal flow (solid black arrow) and collateral filling of blocked RCA from LCX (open black arrows). (D and E) Intraoperative photographs of (D) giant RCA aneurysm and (E) aneurysm opened prior to resection revealing a large quantity of organized thrombus.
Following the establishment of cardiopulmonary bypass and circulatory arrest, the patient underwent a surgical resection of the aneurysmal portion of the ascending aorta with insertion of an Intergard woven aortic arch graft (Macquet, Rastatt, Germany) and reimplantation of the great vessels. The giant RCA aneurysm was prominent on the anterior surface of the heart (Fig. 2D). The RCA and LAD
aneurysms were opened and found to contain a large quantity of thrombus (Fig. 2E). The aneurysms were resected, and the patient received three coronary artery bypass grafts (left internal mammary artery to LAD and saphenous vein grafts from aortic graft to RCA and LCX). The patient developed low cardiac output and expired shortly following surgery.