Spontaneous Rupture of a Left Main Coronary Artery Aneurysm

Abstract

W e report a case of left main coronary artery (LMCA) aneurysm rupture while the patient was hospitalized and immediately after imaging with 2 noninvasive cardiac modalities.An 85-year-old man with history of atrial fibrillation, prostate cancer, hypertension, and hyperlipidemia presented with sudden lightheadedness, chest pressure, and junctional bradycardia (heart rate, 40 bpm). He was admitted to a telemetry bed; warfarin was held and unfractionated heparin was administered. The following day, heparin was held because of supratherapeutic-activated partial thromboplastin times. Transthoracic echocardiogram was performed demonstrating normal ejection fraction, normal wall motion, mild aortic root dilatation, and no pericardial effusion; nothing unusual about the coronary anatomy was noted. Computed tomography coronary angiography to evaluate for coronary artery disease and computed tomography of the chest with contrast to evaluate for pulmonary embolism were performed shortly afterward. Preliminary reports for these studies indicated no pulmonary embolus, mildly aneurysmal thoracic aorta, no thrombus in the left atrial appendage, and <50% stenosis of the left anterior descending ostium. A subsequent final interpretation reported an aneurysmal LMCA (Figure 1). Shortly after returning to his room, the patient developed sudden, severe hypotension and left chest discomfort. Intravenous fluids and vasopressors were administered with minimal effect. Urgent repeat transthoracic ECG showed a new, large pericardial effusion with tamponade ( Figure 2). Because of refractory hypotension, emergency pericardiocentesis was arranged.The patient arrived at the cardiac catheterization laboratory awake but with a blood pressure of 70/30 mm Hg. An arterial catheter was placed, a right heart catheter was advanced to the pulmonary artery, and subxiphoid pericardiocentesis was performed with echocardiographic monitoring; agitated saline injections confirmed correct placement of the drainage catheter. Bright red blood was obtained with pericardiocentesis. After removal of ≈120 cc, the patient became hypertensive to a systolic blood pressure >200 mm Hg; vasopressors were stopped. Within 60 seconds the patient complained of chest pain and became asystolic; resuscitation ensued. Echocardiography revealed no new structural changes but minimal myocardial contractility. Coronary angiography revealed disruption of the LMCA, and contrast pooling within the ascending aorta did not opacify the right coronary artery (Figure 3; Video I in the online-only Data Supplement). The aortic root appeared narrow but not disrupted. Thrombectomy and angioplasty were unsuccessful in restoring normal flow or cardiac function and the patient was pronounced dead.Postmortem examination revealed the following: (1) a ruptured LMCA aneurysm with hematoma extending into the mediastinum and atrioventricular sulcus compressing the orifice of an otherwise normal right

Bilateral coronary artery fistulas with a giant coronary aneurysm complicated by aneurysm rupture

“…[7,8] From the patient's medical history, CT scanning, and resected tissue histopathology, we thought the huge mass may have occurred due to the giant aneurysm rupture, enwrapped, and organization. Rupture of a coronary artery aneurysm is extremely rare, although it was reported in the literature that acute coronary aneurysm rupture caused cardiac tamponade, unconsciousness, and even death, [9,10] but chronic aneurysm rupture like this case has not been described previously. Until now the best treatment of giant coronary aneurysm is not clear because of its rarity, surgical resection may be the right choice for the potential serious complications like this case.…”

Giant right coronary artery aneurysm mimicking a right intra-ventricular mass: a case report

“…Coronary artery aneurysms are usually found either as an incidental finding at angiography, or in acute rupture with hemopericardium and tamponade [7], or myocardial infarction due to coronary thrombosis [8]. However, it is extremely rare that coronary artery aneurysms can be misleading as para-cardiac or intra-cardiac masses [9].…”

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“…Ruptured aneurysm is a rare complication of CAA, besides thrombosis, embolization and ischaemia (Daneshvar et al 2012). Once CAA is ruptured, it can cause cardiac tamponade and sudden death can occur.…”