Saphenous Vein Graft Aneurysm Causing Pulmonary Artery Compression With Exercise
A 77-year-old man presented with dyspnea. A left sternal edge systolic ejection murmur was noted. He had undergone coronary artery bypass grafting with a saphenous vein graft to the left anterior descending artery 34 years earlier, complicated by graft degeneration 10 years later, necessitating repeat surgery (left internal mammary artery to left anterior descending artery).
A rest/exercise echocardiogram demonstrated normal rest and exercise left ventricular function with no ischemia. The right ventricle was mildly dilated at rest, with mild systolic impairment and further dilatation and hypokinesis with exercise. The resting right ventricular systolic pressure was 50 mm Hg plus right atrial pressure (RAP), increasing to 100 mm Hg plus RAP with exercise and falling to 60 mm Hg plus RAP after exercise. The pulmonary artery (PA) systolic pressure gradients at rest and exercise were 50 and 95 mm Hg, respectively.
Invasive investigations revealed a PA gradient of 20 mm Hg, right ventricular systolic pressure of 40 mm Hg, PA pressure of 20/4 mm Hg, and a large, partially thrombosed aneurysm of the original vein graft (Figure 1). The left internal mammary artery graft to the left anterior descending artery was patent. Computed tomography (Figure 2) confirmed a 6.3 cm graft aneurysm compressing the PA (arrow). Accordingly, the aneurysm was coiled with abolition of flow.
His breathlessness subsequently improved. Exercise echocardiography 17 months later revealed normal resting right ventricular systolic pressure (21 mm Hg plus RAP), increasing to 32 mm Hg plus RAP with exercise, with a peak systolic PA gradient at maximum exercise of only 22 mm Hg.
This case represents a rare example of a saphenous vein graft aneurysm causing dynamic PA compression as arterial pressure within the aneurysm rose with exercise.
- © 2015 American Heart Association, Inc.