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Largest Coronary Aneurysm Successfully Excised, Repaired: Presented at CHEST

By Ed Susman

MONTREAL, CANADA -- November 3, 2005 -- Doctors say they have successfully treated a patient with what appears to be the largest coronary artery aneurysm reported in the medical literature.

"This right coronary artery aneurysm measured 7 cm by 11 cm - about the size of an average apple," said Simon Topalian, MD, cardiology fellow, Cooper University Hospital, Camden, New Jersey, United States.

He noted that the normal right coronary artery is measured in millimeters -- not centimeters. "This aneurysm was huge," he said in his oral report here on October 31^st at the American College of Chest Physicians Annual Meeting (CHEST).

After scrutinizing the medical literature, Dr. Topalian said he believes his patient had the largest coronary aneurysm ever reported. Other candidates were as large as 5 to 6 cm.

"I certainly have never heard of any aneurysms this large," said Peter McKeown, MD, chief of surgery, Veterans Affairs Medical Center, and consulting professor of surgery, Duke University, Durham, North Carolina, United States.

"This aneurysm, while certainly rare, was also unusual in that the patient experienced some pain and discomfort - something that can easily be appreciated with a lesion of this size," McKeown said. Most aneurysms of the coronary arteries are asymptomatic and are discovered by coincidence, such as being seen as an abnormality on a chest scan taken for another purpose.

Dr. Topalian said his patient, a 61-year-old man with high blood pressure and high cholesterol, complained of consistent retrosternal and epigastric pain over several months. The rest of his physical examination was unremarkable, Dr. Topalian said. A chest x-ray was suggestive of a hiatal hernia, but a chest scan using computer-assisted tomography and magnetic resonance imaging indicted sinus of Valsalva aneurysm.

An attempt to perform angiography was limited because the right coronary artery could not be engaged, but nonselective dye injection suggested a large aneurysm. Transesophageal echocardiography made it easier to visualize the huge lesion.

The lesion was resected during coronary artery bypass graft surgery. The resection took about 75 minutes to complete. Dr. Topalian said the patient suffered a small right ventricle myocardial infarct during the procedure, but otherwise recovered and continues to improve 1 year later.

"The cardiothoracic team did an impressive job in managing this unusual case, which had the potential for a catastrophic outcome," Dr. McKeown said.

Dr. Topalian said that while such cases are rare, doctors should keep in mind the possibility of coronary artery aneurysms in patients complaining of chest pain. "As we have seen in this case," he said, "the size can be very large and its diagnosis may require more than 1 imaging modality."

Dr. McKeown concurred. "It is not real common, but it can occur and should be considered as a possibility when doing patient work-up," he said.


[Presentation title: Right Coronary Aneurysm: The Largest Aneurysm Reported.]

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