Giant Aneurysm of the Right Coronary Artery Compressing the Right Heart
A 45-year-old woman with a 5-year history of treated essential hypertension presented with a 2-month history of exertional dyspnea and a 2-week history of intermittent palpitations. Two weeks earlier, she presented to the emergency department of another hospital with palpitations, but these had terminated on arrival. She was told her ECG displayed “low voltages.” During the next 2 weeks, she became increasingly dyspneic, feeling short of breath most of the time. She had a sensation of fullness in the chest, frequent palpitations, and ankle edema, so she was referred to a cardiologist. An echocardiogram revealed the presence of a large blood-filled sac markedly compressing the right heart (Figure 1A through 1C). A CT scan of the thorax confirmed the presence of this sac, which measured 9.6 cm maximum diameter (Figure 2). A differential diagnosis of a sinus of Valsalva aneurysm, a giant right coronary artery aneurysm, or a pseudoaneurysm of the aortic sinus was made. She was referred for surgery because of the severity of her right heart compression and the possibility of rupture of the blood-filled sac. Surgical exploration confirmed that the sac was a true right coronary artery aneurysm, communicating proximally with the right coronary artery ostium and distally with the distal right coronary artery (Figure 3). The right coronary artery was ligated proximally, the aneurysm was excised, and a saphenous vein conduit grafted to the distal vessel. Postoperatively, the patient complained of excessive fatigue and occasional swelling of the ankles. Echocardiography revealed mildly impaired right ventricular function with moderate tricuspid regurgitation. Cardiac catheterization confirmed these findings, but because the right atrial pressure remained low (V wave is 8 mm Hg), we elected to continue with medical management initially.