Myocardial infarction due to congenital coronary arterial aneurysm (with successful saphenous vein bypass graft)

Imaging of coronary artery anomalies

Coronary artery anomalies (CAA) are uncommon congenital variations in coronary anatomy, occurring in 0.2% to 1.2% of the general population, the majority of which are detected incidentally and have little clinical significance. A minority of CAA, primarily due to an interarterial course, is clinically significant, and may present with symptoms of myocardial ischemia, malignant ventricular arrhythmias, and even sudden cardiac death. Until recently, CAA were primarily detected at catheter coronary angiography. With recent advances in multidetector computed tomography (CT) technology and the use of electrocardiographic gating, coronary CT angiography provides an exquisite omnidimensional display of the anomalous coronary arteries and their relation to the adjacent structures noninvasively, and is the diagnostic test of choice. Understanding CAA morphology and clinical significance of CAA is important for establishing a diagnosis, and is essential for appropriate patient management and treatment planning.

Coronary pseudoaneurysm: An uncommon cause of P.U.O. after a common procedure

INTRODUCTION

Pyrexia 2 months after a coronary procedure is usually an unrelated event; we came across a rather uncommon cause of delayed appearance of fever related to subacute development of pseudoaneurysm and pericardial effusion secondary to leakage from the pseudoaneurysm after primary angioplasty of LAD, and to the best of our knowledge pseudoaneurysm leak as a cause of prolonged pyrexia is not reported in the literature.

BACKGROUND

Two and half months after successful primary angioplasty with stent implantation for an acute myocardial infarction, we were confronted with an unexplained fever of prolonged duration, after extensive work the cause of unexplained pyrexia was found to be related to development of hemorrhagic pericardial effusion secondary to leak from coronary pseudoaneurysm. The pseudoaneurysm was located in ostium of left anterior descending coronary artery. Despite review of the literature and an examination of the procedural data, we were unable to explain the cause of pseudoaneurysm formation. We assume that either the guidewire perforated the arterial wall when it passed the occlusion or a dissection not visualized angiographically, provoked this phenomenon.

Coronary artery anomalies

Coronary artery anomalies are uncommon findings but can be of significant clinical importance in a small number of individuals. Clinical presentation depends on the specific anomaly. Most coronary artery anomalies are benign and clinically insignificant, however, some anomalies are potentially significant and can lead to heart failure and even death. Noninvasive imaging has emerged as the preferred way to image coronary anomalies. Both electron beam computed tomography (EBCT) and magnetic resonance angiography (MRA) are useful for the diagnosis of anomalous coronary arteries. Recently, MDCT has also proven to be very useful in the detection and characterization of anomalous coronary arteries. This chapter will review the appearance of the most commonly encountered coronary anomalies on MDCT.

An unusual combination of myocardial bridging and coronary artery aneurysm identified on 64-detector coronary angiography

Coronary artery aneurysm is an uncommon finding. It is defined as a dilated coronary artery which exceeds the diameter of the normal adjacent vessel by 1.5-2 times. Although theorized mechanisms include atherosclerotic coronary artery disease (CAD) and iatrogenic causes such as the use of percutaneous coronary interventions (PCI), the natural history and prognosis of this disease remain obscure. We describe a case of a 75 year old man who was found to have a long segmental myocardial bridge immediately followed by a 5 mm inner diameter aneurysm in the left anterior descending artery (LAD) detected on 64-detector cardiac computed tomography (64-CT). The post myocardial bridge aneurysmal dilatation in this case is unique, and has not been previously described. With the advent of 64-CT, more incidental cardiac anomalies and irregularities are likely to be found. In the end, the question as to the clinical significance of these findings and their treatment remains controversial. We report this novel case and review the literature for recommendations on treatment and management of patients with coronary aneurysms.

Giant aneurysms of coronary arteries and saphenous vein grafts: angiographic findings and histopathological correlates

INTRODUCTION

Giant aneurysms that develop in native coronary arteries or saphenous vein grafts are morphologically defined as abnormally expanded outpouching vascular structures >4 cm in diameter. The location, morphology, and content of giant aneurysms account for adverse cardiovascular effects.

METHODS

Two cases of giant aneurysms were studied comprehensively by noninvasive and invasive cardiac methods and subsequent histopathology. The first patient had a giant aneurysm that developed over a course of several years in a saphenous vein graft whereas the second patient had a giant aneurysm occurring within a native coronary artery. Accompanying clinical and angiographic findings are described.

RESULTS

Atherosclerosis and thrombosis were among the prominent histopathological findings.

CONCLUSIONS

Atherosclerosis and associated thrombosis within giant aneurysms result in obstruction of flow, distal embolization, and development of acute coronary syndromes including recurrent ischemic chest pain, unstable angina, and acute myocardial infarction. The options for clinical management of giant coronary or vein graft aneurysms include surgical excision, percutaneous coil occlusion and stent deployment, or medical approach.

Surgical treatment of a coronary artery fistula with concomitant saccular coronary artery aneurysm: a case report

An extremely rare case of a coronary artery fistula with a concomitant saccular aneurysm is presented. A 65-year-old woman, who had a history of chest bruising 5 years earlier, suffered from chest pain, which was diagnosed as being due to left coronary artery-pulmonary artery fistulae concomitant with a giant saccular coronary artery aneurysm. Suture closure of the afferent coronary artery to the aneurysm, aneurysmorrhaphy, and transpulmonary closure of coronary artery-pulmonary artery fistulae were performed. The postoperative course was uneventful and the patient was well at 3 months after the operation. Because the risk of surgery appears to be less than the potential development of fatal complications, it is recommended for the treatment of coronary artery fistula with a concomitant saccular aneurysm.

Coronary artery aneurysm after stent implantation

A coronary artery aneurysm that developed 6 months after coronary stent implantation in the left anterior descending artery, was treated by double coronary artery bypass grafting due to restenosis of the affected vessel and progression of right coronary artery stenosis. Although the poststenting aneurysm initially remained postoperative angiography showed that it had disappeared. In addition to thrombotic occlusion, another mechanism behind its disappearance may be that geometric changes of the implanted stent caused by heart retraction during surgery closed the entrance to the aneurysm.

Coronary artery aneurysms--a case study and literature review

Coronary artery aneurysms are detected with increasing frequency owing to the advent of coronary angiographies. Although most patients with coronary artery aneurysms are asymptomatic, manifestations of myocardial ischemia may occur. The case described herein serves as a basis for a discussion of the pathogenesis, clinical manifestations, detection, and treatment of coronary artery aneurysms.

Fate of nonobstructive aneurysmatic coronary artery disease: angiographic and clinical follow-up report

The incidence of coronary aneurysmatic dilatation without coronary stenosis is rare, and the clinical course of such an entity is unknown. We present five adult patients, four men and one woman, with such an anatomic finding. The age range was 44 to 60 years. In four patients the aneurysmatic dilatations involved multiple coronary sites. The clinical course in all five patients was suggestive of coronary insufficiency. Despite no obstructive disease, two of the patients developed transient ischemic ECG changes accompanied by chest pain, and another two patients demonstrated ischemic exercise nuclear ventriculography response. In time, all five patients developed acute myocardial infarction and recatheterization revealed complete occlusion of a previously nonstenosed aneurysmatic vessel. More information is needed in order to guide therapy. However, prevention of thrombus formation and close follow-up is highly recommended.

Large multiple coronary artery aneurysm in adult patients: a report on three patients and a review of the literature

Three cases of large multiple coronary aneurysms, situated on both right and left coronary arteries, were seen in three middle-aged adult patients. These patients were hospitalized for myocardial infarction in two cases and for angina pectoris in the third case. On the coronary angiogram, the coronary lesions were quite unusual as there were multiple voluminous aneurysms on both coronary arteries without evidence of atherosclerotic lesions of the remainder of the coronary tree. These lesions did not seem to be congenital or atherosclerotic, and it was postulated that these lesions might have been the sequelae of a mucocutaneous lymph node syndrome although no previous history of this condition could be found in these three patients.

Surgical management of an aneurysm of the left main coronary artery

A 28-year-old woman underwent cardiac catheterization three months after sustaining an acute anterolateral myocardial infarct. An aneurysm of the left main coronary artery was found at angiography and also was visualized by two-dimensional echocardiography. The patient had no evidence of atherosclerotic vascular disease. At operation, vein grafts were placed to bypass the aneurysm and the orifice of the left coronary artery was oversewn to exclude the aneurysm from the coronary circulation.

Atheromatous coronary artery ectasia

Of 431 consecutive patients who underwent coronary arteriography during the twelve month period ending December 1976, 23 (5%) had angiographically documented coronary artery ectasia. Of these only five had "pure" or isolated ectasia, whilst 18 had ectatic disease combined with coronary artery stenoses. Clinical findings that are significantly associated with ectasia are male predominance (96%), abnormal lipid patterns (64%), a positive family history of coronary artery disease (57%) and previous hypertension (50%). Anatomically, ectasia most often involved the right coronary artery (96%), then the circumflex artery (75%) and the left anterior descending artery (57%). Only seven (five with severe proximal stenoses) of the 28 patients had coronary artery bypass grafts. Care should be taken not to overdiagnose narrow segments between ectatic, dilated segments as being obstructions. Failure to appreciate this resulted in two patients with isolated coronary artery ectasia having bypass grafts performed with little relief of their symptoms.

Congenital fistula of the right coronary artery-left ventricle--a case report

While the incidence of right coronary artery-left ventricle fistulae is low, cardiac catheterization, ascending aortogram and selective coronary angiogram led us to suspect the presence of such a fistula in a 10-year old female patient. Arteriorrhaphy with additional ligation was performed and the patient is in good health more than one year after surgery.

Coronary artery aneurysm

The case is presented of a 28-year-old woman with systemic vasculitis, aortic insufficiency, and an aneurysm of the proximal right coronary artery. More than 100 patients with coronary artery aneurysm have been reported, and this represents the twenty-first case treated surgically. Coronary artery aneurysms occur more frequently than previously realized and are seen in approximately 1.5% of patients with coronary artery disease. In addition to arteriosclerotic aneurysm, other common types of coronary aneurysm include those occurring congenitally or from mycosis, dissection, trauma, vasculitis, or periarteritis nodosa. Because of the risk of thrombosis and rupture, aneurysmectomy and saphenous vein bypass grafting are recommended for all but small, diffuse, or multiple aneurysms or dissecting aneurysms.

Traumatic right coronary artery-right ventricular fistula with retained intramyocardial bullet

A case of traumatic right coronary artery-right ventricular fistula secondary to a gunshot wound is presented. In addition, the bullet was retained within the interventricular septum. The diagnostic approach, surgical findings and operative procedure of this and other reported cases are discussed. Several key points are emphasized. First, extended follow-up is necessary after trauma to the heart since fistulas may develop years after the initial injury. Second, surgery is generally indicated for fistulas although some data are presented suggesting that small to moderate fistulas may be treated medically. Third, if surgery is undertaken, very careful operative technique must be utilized to locate and close the fistula. Surgical treatment of choice may be coronary arterial ligation with a distal bypass graft if necessary. Postoperative evaluation is mandatory because fistulas may recur. Indications for removal of a foreign body within the myocardium are also discussed.

Aneurysms of the coronary arteries in infants and children. A review, and report of six cases

In recent years large numbers of the so-called "mucocutaneous lymph node syndrome" or "Kawasaki's disease" have been described by Japanese workers, but instances of this disorder are only now being reported as isolated cases by European or North American physicians. The disease has, therefore, been considered to be a new entity. One of its most striking features is the development of aneurysms of the coronary arteries in infants or children, which may lead to sudden death. Aneurysms of the coronary arteries in childhood are rare, and hence it was considered relevant to report six such cases, and to examine their possible relationship to Kawasaki's disease. The pathological changes underlying the latter disorder are not well known; they are considered to be indistinguishable from infantile polyarteritis nodosa. A diagnosis of polyarteritis nodosa was also thought to be most likely to apply in the cases presented here, particularly in view of the frequency with which aneurysms of the coronary arteries have been found in this disorder. In the absence of valid pathological distinctions between Kawasaki's disease and infantile polyarteritis nodosa, the question arises whether these entities are, in fact, different, and whether Kawasaki's disease is the new entity it is assumed to be.

Coronary artery aneurysms: study of the etiology, clinical course and effect on left ventricular function and prognosis

Coronary artery aneurysms were found in 16 men between 37 and 62 years of age, mean 51 years. Aneurysms were of two types: saccular and fusiform. They involved the right coronary artery in 13 (87 per cent), the circumflex artery in eight (50 per cent) and the left anterior descending artery in five (31 per cent). In some patients, more than one vessel was involved. Twelve patients presented with angina pectoris, three with congestive heart failure and one with both. Five were in functional class II, eight were in class III and three were in class IV at the beginning of the study. The electrocardiogram showed evidence of previous myocardial infarction in four patients; four patients had left ventricular hypertrophy, one had left axis deviation, one had left bundle branch block, one had right bundle branch block, two had first degree atrioventricular block and seven had abnormalities in the S-T segment and T wave. Obstructive coronary disease was present in all; the obstruction score was from 1 to 4 in three patients, from 5 to 9 in four patients and from 10 to 14 in the remaining nine. Similar aneurysms were found in the pulmonary artery of one patient and in the abdominal aorta of three patients; in seven of 14 patients with adequate venous angiograms, varicosities of the coronary venous tree were observed. Left ventricular dysfunction and angina pectoris were noted in patients with significant obstructive coronary disease (greater than 70 per cent) and also in patients without obstruction but with coronary aneurysms. Ten patients were treated surgically; nine underwent aortocoronary bypass and one mitral valve replacement. Criteria for bypass was the presence of obstructive disease and medically unresponsive angina pectoris. All but one surgically treated patient showed improvement. The functional class in medically treated patients was unchanged. Fourteen patients were still alive at the completion of the study. The findings of this study suggest that angina pectoris and left ventricular dysfunction can occur with coronary artery aneurysm without coronary artery obstructions. Coronary aneurysms may be a subset of atherosclerosis, and this process may involve other vascular territories. The prognosis in those patients appears to be no worse than in patients with obstructive coronary disease and no aneurysms.

Arteriosclerotic coronary arterial aneurysms in a 49-year-old man with crescendo angina: family history, natural course and prevalence

In a 49-year-old man with crescendo angina, elevated serum cholesterol level and an old posterior myocardial infarction, selective coronary arteriography showed multiple arteriosclerotic aneurysms of the right coronary artery associated with extensive and severe arteriosclerotic disease of the left coronary artery. The patient's mother and brother have both died of a myocardial infarction. Another brother suffers from angina and has documented arteriosclerotic coronary artery disease. Two sisters suffer from angina as well. The possibility of embolization of distal vessels from a friable clot of the aneurysms as a cause of the patient's infarction is discussed. To the best of our knowledge, this is the tenth patient with nonfistulous arteriosclerotic coronary artery aneurysm diagnosed and documented angiographically ante mortem. Including the present case and reviewing the literature, the prevalence of this condition among nonfistulous coronary aneurysms diagnosed ante mortem is 35 per cent and henceforth cannot be regarded as an incidental autopsy finding in cardiac asymptomatic patients.

Recognition and operative management of patients with arteriosclerotic coronary artery aneurysms

Arteriosclerotic aneurysms of the coronary arteries have been noted in 38 patients undergoing cardiac surgical procedures. Age, sex, and risk factors are similar to those in other patients with coronary artery disease. A high incidence of previous myocardial infarction (24 of 38) is related to the frequency of clot formation and embolism associated with such aneurysms. There is also an increased risk of perioperative infarction following coronary artery bypass grafting if the suture line involves the aneurysm wall (6 of 6), but not when sutures are placed away from it. The importance of recognition and proper operative management is stressed.

Coronary artery aneurysm. A review of the literature with a report of 11 new cases

In a prospective study, 11 (1.5 percent) of 742 patients had angiographically proven coronary artery aneurysms. The clinical picture was similar to that of patients with severe coronary artery disease. The coronary artery aneurysms were multiple and were associated with extensive coronary atherosclerosis in ten of the 11 patients. Left ventricular function was impaired when measured by end-diastolic pressure, end-diastolic volume, and ejection fraction. Segmental left ventricular contraction was severely abnormal. The abnormality of segmental contraction, distribution of coronary artery obstructions, an presence of collateral circulation were not different from other patients with severe occlusive coronary atherosclerosis. These 11 cases plus the 23 previously reported ante mortem form the total reported in world literature. The etiology of cornonary artery aneurysms is most commonly atherosclerosis (17/34, or 50 percent). The natural history of this condition is not known. Because of the severe atherosclerosis and poor distal-vessel run-off, most patients are not considered good surgical condidates; however, 15 patients have had coronary arterial surgery, and 13 have survived the immediate postoperative period with some improvement of symptoms.

Bilateral nonfistulous congenital coronary arterial aneurysms

A 15 year old boy collapsed and died after participating in a basketball game. Autopsy revealed bilateral congenital coronary arterial aneurysms. The diagnosis was made post mortem but, retrospectively, might have been suspected during life, even before angiography. The clues to the correct diagnosis were chest pain, a systolic and diastolic murmur and a mass on the right heart border in the chest roentgenogram.

Bilateral arteriosclerotic coronary arterial aneurysms successfully treated with saphenous vein bypass grafting

A man with ischemic heart disease was discovered to have bilateral coronary arterial aneurysms that were sucessfully treated with saphenous vein grafting. Preoperative coronary arteriograms revealed a tight luminal stenosis at the proximal end of the large aneurysm in the left anterior descending artery, suggesting poststenotic dilatation as an etiologic or contributing factor. The right coronary artery was totally occluded proximally, but was noted to be aneurysmal at operation. This is the 14th published case of nonfistulous coronary arterial aneurysm diagnosed in vivo, and the first associated with proximal luminal stenosis.

Congenital coronary artery aneurysms

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