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J Thorac Cardiovasc Surg 2006;131:1396-1397
© 2006 The American Association for Thoracic Surgery
Brief Communication |
a Department of Cardiothoracic Surgery, Clinica Pineta Grande, Castel Volturno (CE), Italy
b Department of Cardiac Surgery, University Federico II, Naples, Italy.
Received for publication January 22, 2006; accepted for publication January 30, 2006. * Address for reprints: Paolo Pepino, MD, Via Manzoni 78, 80123, Naples, Italy. (Email: paolo.pepino{at}fastwebnet.it).
Coronary artery aneurysm (CAA) is rare, its etiology is atherosclerotic in the majority of cases, and the right coronary artery (RCA) is the site of predilection. Usually its size remains constant or it enlarges slowly.
1
Therefore, the presence of a CAA is not always considered to be a surgical indication.
2,3
Anticoagulation and/or antiaggregation are the recommended treatments.
Rapidly expanding right CAA is different; such an aneurysm may rupture with potentially lethal consequences.
We describe the case of a successful repair of a rapidly expanding right CAA with prompt surgical correction.
Clinical Summary
A 50-year-old male patient was admitted to our hospital for coronary angiography in June 2003. He was completely asymptomatic and he denied any history of inflammatory or connective tissue disease. The electrocardiogram showed an abnormal ST tract. Results of the stress test were negative, but he smoked 40 cigarettes per day, was dyslipidemic and hypertensive, and had a positive family history of ischemic heart disease. Coronary angiography revealed normal coronary arteries but with a slow flow of contrast medium in the coronary bed and an aneurysm (Figure 1, A) of the RCA. The patient was prescribed warfarin (international normalized ratio of 2.5) and was dischared from the hospital.
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At surgery, the right CAA was soft on palpation and bluish. To facilitate isolation of the aneurysm from the surrounding myocardium and to preserve the sinus node artery, we preferred to use cardiopulmonary bypass (CPB). During normothermic CPB, the aorta was clamped and myocardial protection was achieved with antegrade and retrograde isothermic potassium cardioplegia. The right CAA was carefully isolated from the surrounding myocardium and was excised. There was no thrombus in the lumen and the wall was very thin. The two stumps of the RCA were oversewn. The proximal tract of the RCA, which gave origin to the sinus node artery, was left intact in situ, thereby preserving antegrade flow into the artery. The right internal thoracic artery (RITA), harvested as a pedicle, was anastomosed end to side to the distal RCA. CPB was interrupted with minimal support (dobutamine 5 
· kg–1 · min–1), the postoperative course was uneventful, and the patient was discharged home in the fifth postoperative day. Histologic examination of the CAA revealed evidence of atherosclerotic inflammation.
Coronary angiography performed 6 months after the operation showed complete disappearance of the aneurysm with the sinus node artery left in situ (Figure 2, A), a patent anastomosis of the RITA to the distal RCA (Figure 2, B), and slow flow of contrast in the coronary bed.
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CAAs are rare, their incidence being 0.2% to 4.9% of all coronary disease.
1,4
Atherosclerosis is the most common cause of CAAs, followed by inflammation, infections, connective tissue disorders, and trauma. The mere presence of a CAA is not a surgical indication, and treatment with anticoagulants and/or antiaggregants is usually recommended.
2,3
When surgery is indicated, the preferred treatment is resection of the aneurysm and reconstruction of the coronary continuity with vein or arterial grafts is the preferred treatment. The exclusion of the aneurysm may sacrifice important coronary collaterals, such as the sinus node artery, which is important in maintaining normal heart rhythm. In fact, its sacrifice during the transseptal approach to the mitral valve is associated with the occurrence of postoperative supraventricular arrhythmia.
5
Therefore, in our patient we attempted to preserve the sinus node artery, which continued to receive blood from the orifice of the RCA while the distal segment of the RCA was revascularized with the RITA.
Our case is interesting because of the rapid enlargement of the aneurysm in the course of 1 year, during which the patient remained completely asymptomatic. CAAs rarely are asymptomatic. They usually present with angina, myocardial infarction, and sudden death; furthermore, their size remains constant or they enlarge slowly. From our experience we can conclude that once a CAA is diagnosed, the surgeon must monitor the patient closely and be prepared to intervene before lethal consequences can appear.
References
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