Right Coronary Artery Aneurysm Communication with the Right Atrium Following Non–ST-Elevation Myocardial Infarction Treated With Coil Embolization
A 78-year-old man with a known right coronary artery aneurysm (CAA) for 24 years presented with persistent chest discomfort to our institution. It was previously noted that his right CAA measured 3.9 × 3.6 cm, was composed of a subtotally thrombosed lumen, and had no fistula formation into adjacent cardiac chambers on both transthoracic echocardiography (TTE) and cardiac MRI (Figure 1 and online-only Data Supplement Movie I, respectively). The cardiac MRI indicated aortic stenosis and an ejection fraction of 55% with no regional wall motion abnormalities. Late gadolinium enhancing demonstrated no evidence of myocardial scar or fibrosis, and normal ventricular function, as well (Figure 2 and online-only Data Supplement Movie II, respectively). The patient’s presentation to our hospital was consistent with a non–ST-elevation myocardial infarction. He was found to have an elevated troponin level of 56 ng/mL (normal troponin ≤0.04 ng/mL), and inferior and posterior ST-T changes on ECG. No continuous murmur was noted; only a previously known crescendo-decrescendo III/VI systolic murmur best heard at the right upper sternal border with radiation to the carotids was auscultated. A 2-dimensional TTE was then performed for evaluation of the right CAA (online-only Data Supplement Movie III). Imaging now demonstrated an increase of the CAA to 7.7 × 6 cm with compression of the adjacent right atrium and tricuspid valve annulus. Furthermore, the ejection fraction was now 35% with posterior-inferior hypokinetic walls. Doppler imaging displayed flow from the CAA into the right atrium (peak systolic gradient of 26 mm Hg and peak diastolic gradient of ≈19 mm Hg) consistent with fistula formation (Figure 3). This finding was also seen on cardiac catheterization. Anticoagulation was initiated, and it was decided that the patient undergo repeat cardiac catheterization for possible intervention.
The patient underwent left and right heart catheterization with echocardiographic guidance. At baseline, evidence of flow from the aneurysm into the right atrium was visualized by TTE. The proximal right coronary artery was balloon occluded to evaluate for evidence of an enlarging burden of ischemia. The patient did not have significant chest pain, new inferior wall motion abnormalities on echocardiography, or new ST elevations, so thrombin injection into the CAA was performed. The CAA subsequently appeared to be completely occluded. However, a small clot was noted to be in the process of migrating through the fistula into the right atrium, so further thrombin injection was halted (online-only Data Supplement Movie IV). Because there was still flow into the CAA by repeat angiography, we switched to a coil embolization strategy (Figure 4). The proximal right coronary artery was then coiled successfully with 6 × 10 mm and 2 × 7 mm Codman Trufill coil (Warsaw, IN). The patient had no complications from the procedure. A follow-up TTE demonstrated a thrombosed, smaller aneurysm with no discernible flow into the right atrium and stable inferior wall hypokinesis (online-only Data Supplement Movie V). The patient was discharged, and a 5-month follow-up TTE demonstrated decreased size of the thrombosed aneurysm to 5.4 × 4.4 cm (online-only Data Supplement Movie VI).
The online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA.112.095505/-/DC1.
- © 2013 American Heart Association, Inc.