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J Thorac Cardiovasc Surg 2009;137:e1-e3
© 2009 The American Association for Thoracic Surgery

Brief Communication

Spontaneous rupture of the dissected coronary sinus mimicking acute coronary syndrome

^a Cardiology Division, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria
^b Department of Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
^c Institute of Radiology, Medical University Innsbruck, Innsbruck, Austria

Received for publication February 6, 2008; revisions received February 6, 2008; accepted for publication February 17, 2008.

^_* Address for reprints: Thomas Bartel, MD, Cardiology Division, Department of Internal Medicine, University of Innsbruck, Anichstr. 35, A-6020 Innsbruck, Austria. (Email: thomas.bartel{at}i-med.ac.at).

Video clip is available online.

 

Coronary sinus (CS) dissection has been described as a complication of pacing electrode implantation only.¹ We report here the diagnosis and surgical therapy of spontaneous rupture of a dissected CS in a patient with acute coronary syndrome (ACS) and circumflex artery (CX) to the CS fistula.

Clinical Summary

ACS was suspected in a 63-year-old man with acute chest pain after physical exertion but with no electrocardiographic signs of acute myocardial infarction. Coronary angiography showed a giant left main coronary artery aneurysm. A very ectatic and calcified CX originated from the aneurysm and drained into a huge CS. There were no coronary stenoses. Transesophageal echocardiographic analysis revealed a possibly hemorrhagic pericardial effusion. Septated echodense structures were found within the CS lumen that were indicative of chronic dissection ( Figure 1, A). Turbulent flow inside the CS was indicative of arterial pressure (Figure 1, B). Cardiac electrocardiographically gated 64-slice computed tomography confirmed a fistula² passing along the left atrioventricular groove, taking a tortuous course with multiple loops before draining into the CS (Figure 1, C and D). The posterolateral and great cardiac veins were also markedly dilated because of chronic pressure overload (Figure 1, E and F). Consequently, a concealed perforation was thought to have caused hemorrhage. At the time of emergency surgical intervention, approximately 300 mL of hemorrhagic pericardial effusion and blood clots was removed. Manipulation of the multisegmented and enlarged CS was avoided. The fistula was closed, the main stem and CX were dissected, and a large part of the diffuse aneurysm was excised ( Figure 2 and Videos E1, E2 and E3), taking care to leave enough tissue behind next to the orifice of the left anterior descending coronary artery and first diagonal branch, which both originated from the aneurysm back to back. A roof was constructed, with part of the aneurysm wall reinforced by pericardium patches to ensure communication between the left anterior descending coronary artery and the intermediate branch. Subsequently, coronary revascularization was successfully completed, with the left internal thoracic artery bypassing the left anterior descending coronary artery and a saphenous vein graft to the largest obtuse-marginal branch. The patient recovered from surgical intervention uneventfully and was discharged home on postoperative day 6.

View larger version (70K): [in this window] [in a new window]   Figure 1. A and B, Enlarged and dissected coronary sinus (A) with turbulent fistular flow (B). 1, Turbulent entrance flow from the coronary sinus into the right atrium; CS, coronary sinus; IVC, inferior vena cava; PE, pericardial effusion; RA, right atrium. C and D, Computed tomographic 3-dimensional view of the heart by using a volume-rendering technique: giant left main coronary aneurysm (anterior view of the heart; C) from which an enlarged, heavily calcified circumflex artery originates, which drains distally into the dilated, septated coronary sinus (posterior view of the heart; D). A, Aneurysm; CS, coronary sinus; CX, circumflex coronary artery; LV, left ventricle; V, dilated posterolateral cardiac vein; 1, the fistula between circumflex coronary artery and coronary sinus. E and F, Computed tomographic axial oblique (E) and coronal oblique (F) planes of the heart. The circumflex artery drains into the dissected coronary sinus (E). The distal posterolateral vein is enlarged and shows thrombus formation and surrounding hemorrhage indicative of a concealed perforation (F). LV, left ventricle; CS, coronary sinus; CX, circumflex coronary artery; V, distal posterolateral vein; P, pericardium; X, hemorrhage; LA, left atrium; RV, right ventricle; 1, the circumflex artery drains into the dissected coronary sinus; 2, thrombus formation in the posterolateral vein.

View larger version (88K): [in this window] [in a new window]   Figure 2. Intraoperative view of the junction between the left main coronary aneurysm and the ectatic circumflex artery (A) and the circumflex artery to the coronary sinus fistula (B). A, Left main aneurysm; CS, coronary sinus; CX, circumflex artery; DX, first diagonal coronary artery; PDA, posterior descending coronary artery.

To our knowledge, this case demonstrates for the first time that (1) spontaneous dissection of the CS can occur because of pressure overload as a result of a CX-to-CS fistula and can be adequately visualized by means of transesophageal echocardiography³; (2) CS dissection can be complicated by pericardial hemorrhage; and (3) CS dissection can mimic not only coronary artery disease by a "steal" phenomenon³ but also ACS caused by painful perforation and should therefore be considered in the differential diagnosis of patients with acute chest pain and pericardial effusion.

Appendix

Supplementary data

Appendix

Supplementary data

Appendix

Supplementary data

Supplementary data

Supplementary data associated with this article can be found in the online version, at doi:10.1016/j.jtcvs.2008.02.036

References

1. Yoda M, Hansky B, Koerfer R, Minami K. Coronary sinus dissection during left ventricular pacing electrode implantation. Ann Thorac Cardiovasc Surg 2007;13:275-277.[Medline]
   
2. De Cicco G, Fucci C, Borghesi A, Lorusso R. Left circumflex coronary artery to coronary sinus fistula. Eur J Cardiothorac Surg 2006;30:559.[Free Full Text]
   
3. Bothe W, Schlensak C, van de Loo A, Beyersdorf F. A fistula between the circumflex artery and the coronary sinus mimics coronary artery disease in a 63-year-old woman. Interact Cardiovasc Thorac Surg 2005;4:81-82.[Abstract/Free Full Text]
   

This Article Full Text (PDF) Video Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Alfred Kocher Johannes O. Bonatti Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Bartel, T. Articles by Metzler, B. Search for Related Content PubMed Articles by Bartel, T. Articles by Metzler, B. Related Collections Coronary disease