Cardiac tamponade due to rupture of coronary artery fistula to the coronary sinus with giant aneurysm of coronary artery: usefulness of transthoracic echocardiography

Acute myocardial infarction due to giant coronary artery aneurysm and arteriovenous fistula: a challenging case report and review of the literature

BACKGROUND

A coronary artery aneurysm (CAA) is an abnormal dilation of a coronary artery segment often accompanied by coronary artery fistula (CAF), leading to communication between a coronary artery and a cardiac chamber or a part of the coronary venous system. Both CAAs and CAFs can present with symptoms and signs of myocardial ischemia and infarction.

CASE PRESENTATION

We describe the case of a 46-year-old woman with non-ST-elevation myocardial infarction (NSTEMI) caused by a "giant" CAA. Various imaging modalities revealed a thrombus-containing aneurysm located at the right-posterior cardiac border, with established arteriovenous communication with the distal part of left circumflex artery (LCx). After initial treatment with dual antiplatelet therapy, a relapse of pain was reported along with a new increase in troponin levels, electrocardiographic abnormalities, reduced left ventricular ejection fraction (LVEF) and thrombus enlargement. Surgical excision of the aneurysm was favored, revealing its true size of 6 cm in diameter. Τhe aneurysm was excised without complications. The patient remained asymptomatic during follow-up.

CONCLUSIONS

Management of rare entities such as "giant" CAAs and CAFs can be challenging. Cases such as this can serve as precedents to facilitate treatment plans and develop consistent recommendations, emphasizing the importance of personalized strategies for future patients.

Giant aneurysm of left circumflex artery branch with fistula to the coronary sinus: a case report

Background

Aneurysm of a coronary artery branch with a fistula is extremely rare. Here, we present a case of giant aneurysm of the left circumflex artery branch with a fistula to the coronary sinus treated successfully with aneurysmectomy.

Case presentation

A 58-year-old woman was referred to our hospital due to an abnormal pericardial mass found by multidetector computed tomography. Imaging examination revealed a dilated left circumflex artery branch with a 30-mm aneurysm. Coronary angiography confirmed a left circumflex artery branch aneurysm with a fistula to the coronary sinus. As percutaneous occlusion of the aneurysm by catheterization was considered unsuccessful, the aneurysm was resected, and the fistula was occluded surgically with excellent outcome. Pathological examination suggested that congenital factors may have contributed to the development of the aneurysm. Computed tomography showed no recurrence of the aneurysm at 1-year postoperative follow-up.

Conclusions

We presented a case of giant aneurysm of the left circumflex artery branch with a fistula to the coronary sinus. This is the first report of the combination of a giant coronary artery branch aneurysm with a fistula to the coronary sinus. Surgical aneurysmectomy should be considered in such cases to avoid fatal aneurysmal complications.

Case Report: Not a Mediastinal Mass! a Ruptured Giant Coronary Aneurysm That Occurred in a Young Man

Introduction

Coronary artery aneurysm (CAA) is a localized coronary artery dilatation that exceeds 1. 5 times the diameter of a standard adjacent segment or the largest coronary vessel. When the expansion is > 2 cm, it is called a “giant” coronary artery aneurysm. Giant coronary artery aneurysm rupture is extremely rare and fatal.

Case presentation

We present a rare case of a 27 years old male with a giant coronary artery aneurysm rupture, but no catastrophic events occurred immediately. He was initially misdiagnosed as having a mediastinal mass with CT (computed tomography). The cardiac ultrasound showed no pericardial effusion. But The cardiac CTA (computed tomography angiography) showed a giant coronary aneurysm rupture with hematoma formation. He eventually underwent surgery and was followed up for 2 months without complications.

Conclusion

We report this case of a ruptured giant coronary aneurysm because of its infrequent occurrence in coronary artery disease. It is tough to distinguish this disease from a mediastinal tumor, and chest MRI and cardiac CTA are crucial tests. Finally, surgical resection may be the right choice for coronary aneurysm rupture. More cases need to be reported to facilitate the preoperative diagnosis of this rare coronary aneurysm.

Dual Aneurysms of the Left Anterior Descending Coronary Artery Initially Detected by Echocardiography

Echocardiographic detection of abnormalities occurring medially and distally in coronary arteries is uncommon and is not well recognized. Herein, we describe an 87-year-old woman with two distinct aneurysms involving a branch of the left anterior descending coronary artery (LAD), one of which communicated with the pulmonary artery (PA). Initially determined via transthoracic echocardiography (TTE), these findings were subsequently validated by coronary computed tomography angiography (CTA). We also present a review of the published studies of multiple coronary artery aneurysms (CAAs) exceeding 20 mm in diameter, focusing on the location, etiology, symptoms, and common ultrasonic characteristics of 30 cases. Echocardiography is a valuable, noninvasive technique for initial detection, monitoring, and follow-up of CAAs, serving to direct further diagnostics.

Fractional flow reserve-guided percutaneous coronary intervention for an intermediate stenosis complicated by a coronary-to-pulmonary artery fistula

A 65-year-old man was referred to our hospital following repetitive chest pain. Invasive coronary angiography showed an intermediate stenosis of the proximal left anterior descending artery (LAD), and a coronary fistula originating distal to the stenosis draining into the main pulmonary artery. To evaluate the functional abnormality arising from the stenosis and coronary steal due to the fistula, fractional flow reserve (FFR) was measured using a pressure wire with pullback recording. The FFR value was 0.74 at the distal LAD, 0.78 distal to the fistula, 0.81 proximal to the fistula (distal to the stenosis), and abruptly increased to 1.0 proximal to the stenosis. Based on these FFR results, percutaneous coronary intervention was performed to the stenosis. After stent placement, the FFR value improved to 0.87 at the distal LAD, and no abrupt pressure gradient was observed beyond the fistula and the stent. FFR-guided intervention with pullback pressure recording could be a useful and practical method to apply in cases with coronary stenosis complicated by coronary fistula in the same vessel.

"Wedge effect" in stenosed coronary artery assessed using a PressureWire: change in pressure waveform during percutaneous coronary intervention in a patient with a coronary artery-left ventricular fistula

In this case report, we describe the recovery of abnormal coronary pressure waveform using a PressureWire Certus during percutaneous coronary intervention in a patient with severe stenosis in the proximal segment of the left anterior descending coronary artery. Since the diastolic pressure in the distal left anterior descending coronary artery was lower than that in the aorta, the pressure waveform before percutaneous coronary intervention represented the left ventricular pressure through a fistula due to a "wedge effect" in the stenosis as if the pulmonary artery wedge pressure determined by a Swan-Ganz catheter reflected the pressure in the distal portion (left atrium). We diagnosed this case coronary artery-left ventricular fistula based on the above findings. PressureWire Certus may be a valuable tool with which to estimate the hemodynamics in a patient with a coronary anomaly.