JTCS Email Content Delivery
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Pinheiro, B. B.
Right arrow Articles by Vieira, G. B.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Pinheiro, B. B.
Right arrow Articles by Vieira, G. B.
Related Collections
Right arrow Myocardial infarction

J Thorac Cardiovasc Surg 2004;128:751-752
© 2004 The American Association for Thoracic Surgery

Brief communication

Surgical management of a giant left main coronary artery aneurysm

Bruno B. Pinheiro, MDa,*, Walter V. Fagundes, MDa, Carlos A. Gusmão, MDb, Antônio M. C. Lima, MDb, Lola H. Santos, MDb, Gustavo B. Vieira, MDb

a Department of Cardiac Surgery, Hospital Santa Genoveva–Clinicord, Av. Concordia 26, zip 74670-430, Goiânia, Brazil
b Department of Cardiology, Hospital Geral de Goiânia, Av. Anhanguera 6479, zip 74110-010, Goiânia, Brazil

Received for publication February 20, 2004; revisions received March 11, 2004; accepted for publication March 15, 2004.

* Address for reprints: Bruno B. Pinheiro, MD, Hospital Santa Genoveva–Clinicord, Av. Concordia 26, zip 74670-430, Goiânia, Brazil
bbpmt{at}cultura.com.br


Dr Pinheiro


Coronary artery aneurysms are noted in 0.15% to 4.9% of patients undergoing coronary angiography. They rarely involve the left main coronary artery (LMCA). In a series of 22,000 coronary angiograms, LMCA aneurysms were found in only 22 patients (an occurrence rate of 0.1%).1 According to Lenihan and coworkers,2 coronary artery aneurysms in patients younger than 33 years of age are congenital, and they have otherwise normal coronary arteries. In most patients older than 33 years and in all patients older than 56 years, coronary artery aneurysms are caused by atherosclerosis.2 The main complication is myocardial ischemia or infarction, but aneurysm rupture can rarely occur. Because of the rarity of LMCA aneurysms, it is difficult to standardize treatment. Various surgical strategies have been adopted, such as reconstruction, resection, or isolation with concomitant coronary bypass.3

We present a case of successful isolation of a giant LMCA aneurysm with simultaneous coronary artery bypass grafting.

Clinical summary

A 27-year-old man with a history of angina pectoris for 4 months was admitted to the hospital because of progressive precordial pain radiating to the back triggered by physical activity. He had a severe blunt chest injury (car accident) with loss of consciousness 8 years previously.

Results of physical examination were within normal limits. The electrocardiogram showed a normal sinus rhythm. The chest radiograph and transthoracic echocardiogram revealed a huge mass adjacent to the pulmonary trunk and left atrial appendage extrinsically compressing the left atrium. The left ventricular ejection fraction was normal (0.70).

Spiral computed tomography and coronary angiography demonstrated a giant LMCA aneurysm (56 mm in diameter) without atherosclerotic coronary disease (Figure 1). There was no evidence suggestive of thrombus or dissection.



View larger version (80K):
[in this window]
[in a new window]
  		Figure 1. A and B, Spiral computed tomographic scan showing a huge mass (56 mm in diameter) adjacent to the pulmonary trunk and ascending aorta (white arrow).. C, Left coronary angiography.

 
The patient was operated on with the aid of cardiopulmonary bypass and antegrade cold blood cardioplegia. The pulmonary trunk was mobilized, and the LMCA aneurysm could be exposed and opened (Figure 2). The orifices of the LMCA, the left anterior descending artery, and the circumflex artery were oversewn. The left internal thoracic artery was used to bypass the left anterior descending artery, and the right internal thoracic artery was used to bypass the diagonal branch. A saphenous vein graft was placed to a marginal branch of the circumflex artery. The aortic crossclamp time was 70 minutes, and the cardiopulmonary bypass time was 95 minutes.



View larger version (78K):
[in this window]
[in a new window]
  		Figure 2. A, Giant LMCA aneurysm (white arrow).. B, LMCA aneurysm opened showing the orifices of the left main artery (arrowheads).. anterior descending artery (white arrow).. and circumflex artery (black arrow)..

 
The histopathologic study revealed an intimal layer with variable fibrosis and localized tears, medial layer dissection, and fresh intramural hematoma. Medial degeneration, cystic medial necrosis, inflammatory infiltrates, and atherosclerotic plaques were not observed microscopically on the surgical specimen. The patient has been asymptomatic for 5 months after the operation.

Discussion

The most common cause of aneurysm of the coronary artery is atherosclerosis. The next is idiopathic, often presumed to be congenital. Other causative factors include Takayasu arteritis, Kawasaki disease, Marfan syndrome, systemic lupus erythematosus, Ehlers-Danlos syndrome, polyarteritis nodosa, bacterial infection, syphilis, septic embolism, and trauma. No familial cases of coronary aneurysm have been reported.2,4

In our patient the LMCA aneurysm could be classified as congenital. Nevertheless, we cannot exclude the possibility that the chest trauma played a central role in the pathogenesis of his aneurysm.

Patients with aneurysms of the coronary artery diagnosed before death are initially seen most often with angina or myocardial infarction. Often, no physical findings related to aneurysm are present, although both systolic and diastolic murmurs attributed to the aneurysm have been reported.4 Rupture of the aneurysm with sudden death is unusual.5

In a few patients chest radiography shows a bulge on the cardiac silhouette or calcium in the aneurysm. Transthoracic echocardiography and computed tomography are potentially noninvasive methods of diagnosis, but their value is not yet established. Definitive diagnosis is obtained with coronary angiography.1,4

Because of the rarity of LMCA aneurysms, it is difficult to standardize treatment. The conservative treatment consists of attempts to prevent thromboembolic complications with anticoagulants and antiplatelet drugs, but the surgical treatment is most widely used to avoid complications (extension, thrombosis, rupture, and coronary embolization). Various surgical strategies have been adopted, such as reconstruction, resection, or isolation with concomitant coronary bypass.3-5

References

  1. Topaz O, DiSciascio G, Cowley MJ, Goudreau E, Soffer A, Nath A, et al. Angiographic features of the left main coronary artery aneurysms. Am J Cardio.. 1991;67:1139–1142
  2. Lenihan DJ, Zeman HS, Collins GJ. Left main coronary artery aneurysm in association with severe atherosclerosis: a case report and review of the literature. Catheter Cardiovasc Diag.. 1991;23:28–31
  3. Lepojärvi M, Salmela E, Huikuri H, Kärkölä P. Repair of an aneurysm of the left main coronary artery. Ann Thorac Sur.. 1996;61:1247–1249
  4. Moses HW, Huddle RA Jr, Nanda NC, Stewart S, Schreiner BF. Surgical management of an aneurysm of the left main coronary artery. Ann Thorac Sur.. 1979;27:569–573
  5. Türkay C, Gölbasi I, Sahin N, Kabukcu M, Bayezid Ö. Surgical management of an atherosclerotic aneurysm of the left main coronary artery. J Thorac Cardiovasc Sur.. 2001;122:626–627[Free Full Text]



This article has been cited by other articles:


Home page
 Asian Cardiovasc. Thorac. Ann.Home page
J.-A. S Lloyd, E. S Weiss, and L. A Vricella
Left Anterior Descending Coronary Aneurysm
Asian Cardiovasc Thorac Ann, January 1, 2009; 17(1): 82 - 83.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Pinheiro, B. B.
Right arrow Articles by Vieira, G. B.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Pinheiro, B. B.
Right arrow Articles by Vieira, G. B.
Related Collections
Right arrow Myocardial infarction

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS