P77 a “Giant” in the Pandora’s Box of Paracardiac Mass

Abstract

In this case report, we describe a giant coronary aneurysm (CAAs) of the right coronary artery occasionally found in a patient that underwent Bentall procedure 18 years earlier for acute aortic dissection. A 77–year–old man, former smoker, with type II diabetes, hypertension, dyslipidaemia, and obesity, was referred to our echo lab for echocardiography in December 2020. His medical history included anteroseptal non–Q–wave myocardial infarction (1983), type A acute aortic dissection treated with Bentall procedure and implantation of mechanical aortic valve (2002), and reparation of abdominal aortic aneurysm (2003). During the echocardiogram a paracardiac mass was incidentally found, in close contact to the right atrium and with a diameter of 60 mm in A4Ch–view, with the appearance of a cystic formation (Figure A). After a few days, a CT angiography was performed, with evidence of 61.6 mm–sized giant aneurysm located in the proximal right coronary artery, characterised by calcified walls, eccentric thrombosis, and compression of the right atrium (Figure B). The patient was subsequently evaluated by the Cardiac Surgery Division. Conservatively management with regular follow–up was performed, because of the high surgical risk of redo and the lack of symptoms. In November 2022 we performed a follow–up echocardiography with evidence of stability of the size of coronary artery aneurysm (Figure C). CAAs are defined as giant when the diameter of the vessel is greater than 20 mm. These pathological entities are extremely rare, with an incidence rate of 0.02%, and aetiologies are various. The most frequent aetiologies comprehend atherosclerosis (about 50% of cases), congenital (17%), arteritis (e.g., Kawasaki disease), connective tissue disease. Our case is characterised by the occasional diagnosis of CAA 18 years after Bentall Surgery, in absence of inflammatory vessels disease. To the best of our knowledge, It’s the largest giant CAA described in literature after Bentall cardiac surgery. Therefore, cardiologists should consider these rare entities when approaching an incidental echocardiographic finding of paracardiac mass, especially in patients with high burden of atherosclerotic disease. This case report underlines furthermore the importance of an integrated approach in the differential diagnosis of a paracardiac mass.