Multiple Left Anterior Descending Artery Aneurysms
A 33-year-old man presented for the third time with an inferior non-ST elevation myocardial infarction (2010, 2013 and 2016), with T wave inversion on the inferior leads of ECG. Previous coronary angiogram had shown an ectatic left anterior descending artery and a non-dominant right coronary artery. After each event he took aspirin and warfarin for 1 year then aspirin alone. The latest coronary angiogram showed an aneurysm of the left anterior descending (LAD) artery at the apex (figure 1). A computerized tomographic coronary angiogram confirmed the aneurysmal dilatation and a further lobulated area partially covered by right ventricular myocardium (figure 2 and 3) but no obvious fistulous communication to the right ventricle. His left ventricular function had decreased from 50% to 40% (by echocardiography) with inferolateral hypokinesia, by the time of his third admission. The patient declined surgical intervention, and remains well at present.
|Figure 1: Coronary angiogram, showing dilated aneurysms at terminal portion of left anterior descending artery (upper arrow for LAD and lower arrow for aneurysms)||Figure 2: Computerized tomographic coronary angiogram, 3D reconstruction, showing aneurysmal dilatation and a further lobulated (arrow) area partially covered by right ventricular myocardium||Figure 3: Computerised tomographic coronary angiogram, showing aneurysmal dilatation and a further lobulated area partially covered by right ventricular myocardium (arrow)|
Coronary artery aneurysm (CAA) is defined as a localized dilatation more than 1.5 times bigger than the diameter of adjacent normal segments and occurs in approximately 1.5–5% of patient undergoing coronary angiography1. In adults, CAA is predominantly atherosclerotic in origin however, other causes include Kawasaki disease, autoimmune disease, trauma, congenital malformation (including coronary artery fistula) and angioplasty2. The majority of patients with CAA are asymptomatic but they may present with angina, myocardial infarction, fistula formation, rupture, or congestive heart failure. The myocardial ischaemia can occur due to coronary steal3. To avoid complications large CAA should be treated surgically with resection of the aneurysm, closure of associated fistulae and possible coronary artery bypass grafting4. We could not demonstrate a fistula but the large lobulated aneurysm indenting the right ventricle suggests a fistula may have been the cause. Due to the distal nature of the aneurysm, ligation, plication of the aneurysms (to stop clot formation within them) with no coronary artery bypass was proposed.
1. Demopoulos VP, Olympios CD, Fakiolas CN, et al. (1997) The natural history of aneurysmal coronary artery disease. Heart. 78: 136-141.
2. Chiusaroli A, Segreto A, De Salvatore S, et al. (2015) Coronary artery aneurysms: case report and treatment overview. Eur Rev Med Pharmacol Sci. 19: 2572-2574.
3. Sommer RJ, Hijazi ZM, Rhodes JF. (2008) Pathophysiology of congenital heart disease in the adult: part I: shunt lesions. Circulation. 117: 1090-1099.
4. Dolapoglu A, Ott DA. (2016) Giant right coronary artery aneurysm associated with a fistula draining into the superior vena cava. Tex Heart Inst J. 43:360-362.
© 2017 Carr et al., Department of Cardiothoracic Surgery, Heart Hospital, Doha, Qatar
Office 18, Level 6, Wing A,
Melange Towers, Hitech City,
Hyderbad, India - 500082