J o u r n a l o f C a r d i o v a s c u l a r C o m p u t e d T o m o g r a p h y 8 ( 2 0 1 4 ) 8 5 e8 7
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofCardiovascularCT.com
Images in Cardiovascular CT
Right coronary artery aneurysm with aneurysmal dilation and thrombosis of the sinoatrial nodal branch mimicking a right atrial mass Jennifer Vaughn MDa, Ambika C. Nayar MDb, Monvadi B. Srichai MD, MSc,* a
Department of Radiology, New York University School of Medicine, New York, NY, USA Department of Medicine, New York University School of Medicine, New York, NY, USA c Department of Medicine, Medstar Georgetown University Hospital, Medstar Heart Institute, 3800 Reservoir Rd, NW, 5PHC, Washington, DC 20007, USA b
article info
abstract
Article history:
Aneurysms of the branches of the coronary arteries are rare. We report a case of a right
Received 12 October 2013
coronary artery aneurysm with aneurysmal dilation and thrombosis of the sinoatrial nodal
Received in revised form
branch presenting as a right atrial mass. The patient underwent multiple imaging evalu-
12 December 2013
ations before coronary CT angiography diagnosed aneurysm and thrombosis of the sino-
Accepted 16 December 2013
atrial nodal branch. ª 2014 Society of Cardiovascular Computed Tomography. All rights reserved.
Keywords: Cardiovascular computed tomography Coronary artery aneurysm Cardiac mass Multimodality imaging Magnetic resonance imaging Echocardiography
A 65-year-old woman with chest pain underwent coronary angiography that showed an enlarged right coronary artery (RCA), no obstructive coronary artery disease, and possible aneurysm in the sinus of Valsalva (Fig. 1A). Echocardiography showed dilated RCA and right atrial mass suggestive of but not definitive for lipomatous hypertrophy, given its presence on only 1 side of the interatrial septum (Fig. 1B; supplementary Movie 1). She was referred for cardiac magnetic resonance (MR) imaging for further characterization of the mass but was lost to follow-up. Cardiac MR performed 2 years later showed
proximal RCA aneurysm and a serpentine, nonenhancing structure that coursed posteriorly along the interatrial septum and posterior right atrium (Fig. 1C,D; supplementary Movie 2). Coronary CT angiogram confirmed proximal RCA aneurysm and delineated aneurysm and thrombosis with peripheral calcification of the sinoatrial nodal branch which was noted to arise from the posterior aspect of the RCA (Fig. 2). Because the patient was asymptomatic, no intervention was undertaken. Coronary artery aneurysms are rare, occurring in 0.3% to 4.9 % of patients undergoing coronary angiography,1 with
Conflict of interest: The authors report no conflict of interest. * Corresponding author. E-mail address: [email protected] (M.B. Srichai). 1934-5925/$ e see front matter ª 2014 Society of Cardiovascular Computed Tomography. All rights reserved. http://dx.doi.org/10.1016/j.jcct.2013.12.015
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J o u r n a l o f C a r d i o v a s c u l a r C o m p u t e d T o m o g r a p h y 8 ( 2 0 1 4 ) 8 5 e8 7
Fig. 1 e (A) X-ray coronary angiography RAO projection shows aneurysm of the proximal RCA with possible aneurysmal involvement of the sinus of Valsalva (asterisk); patent and normal caliber distal RCA. (B) Echocardiogram in apical 4-chamber view shows prominence of the right side of the posterior portion of the interatrial septum (arrow). (C) Steady state free precession gradient echo cine CMR image in 4-chamber view shows thickening along the right atrial posterior wall and interatrial septum (arrow). (D) After contrast, inversion recovery 4-chamber CMR image shows a tubular serpentine nonenhancing structure (arrow) that appears to arise from the proximal RCA and courses posteriorly to the interatrial septum and posterior right atrium where it assumes a rounded shape. CMR, cardiac magnetic resonance; RAO, right anterior oblique; RCA, right coronary artery. sinoatrial nodal artery aneurysms extremely rare.2 Atherosclerosis remains the most common cause of coronary artery aneurysms although they are also associated with congenital malformations, connective tissue disorders, vasculitis, infectious causes, trauma, and neoplasms.3 Coronary CT angiography can provide precise information about characteristics of coronary artery aneurysms such as diameter, length, shape, number, and associated stenoses. In addition 3-dimensional evaluation helps to delineate the anatomic location and relationship to surrounding structures.4 In children or in patients for whom there is concern for radiation exposure, echocardiography may be useful for evaluating proximal coronary segments, but coronary MR angiography is often the alternative imaging test capable of providing similar information to coronary CT angiography.4 Management is variable with surgery typically considered for aneurysms 3 to 4 times the size of the reference vessel, when there are progressive symptoms despite medical management or when associated complications such as fistula formation occur.2,3,5 After multiple imaging modalities, our patient’s condition was diagnosed by coronary CT angiography as thrombosed aneurysm of the sinoatrial nodal branch. She was managed medically and underwent workup for vasculitis and connective tissue disorders.
Supplementary data Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.jcct.2013.12.015.
references
1. Abou Eid G, Lang-Lazdunski L, Hvass U, et al. Management of giant coronary artery aneurysm with fistulization into the right atrium. Ann Thorac Surg. 1993;56:372e374. 2. Kim SH, Jang IS, Ouck C, et al. Giant atherosclerotic aneurysm of the sinoatrial nodal artery. J Thorac Cardiovasc Surg. 1997;114:280e282. 3. John LC, Hornick P, Davies DW, Banim SO, Rees GM. The role of surgery in management of solitary coronary artery aneurysm. Eur J Cardiothorac Surg. 1991;5:440e441. 4. Diaz-Zamudio M, Bacilio-Perez U, Herrera-Zarza MC, et al. Coronary artery aneurysms and ectasia: role of coronary CT angiography. Radiographics. 2009;29:1939e1954. 5. Koito R, Oku T, Satoh H, et al. Right ventricular myocardial infarction and late cardiac tamponade due to right coronary artery aneurysm: a case report. Jpn J Surg. 1990;20:463e467.
J o u r n a l o f C a r d i o v a s c u l a r C o m p u t e d T o m o g r a p h y 8 ( 2 0 1 4 ) 8 5 e8 7
87
Fig. 2 e Coronary CT angiogram. (A) Three-dimensional volume-rendered image shows proximal dilation of the RCA (*) with normal caliber vessel distally. The right heart chambers are not well opacified, but there is evidence of a calcified mass (arrow) that is posterior to the RCA. (B) Multiplanar reformatted axial view shows proximal RCA aneurysm (*). (C) Multiplanar reformatted image show aneurysmal dilation and thrombosis with peripheral calcification of the sinoatrial nodal branch (arrow). (D) Thin maximum intensity projection image shows thrombosed sinoatrial nodal branch (arrow) arising from the posterior aspect of the proximal RCA (*). Ao, aorta; LA, left atrium; LV, left ventricle; RCA, right coronary artery.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofCardiovascularCT.com
Images in Cardiovascular CT
Right coronary artery aneurysm with aneurysmal dilation and thrombosis of the sinoatrial nodal branch mimicking a right atrial mass Jennifer Vaughn MDa, Ambika C. Nayar MDb, Monvadi B. Srichai MD, MSc,* a
Department of Radiology, New York University School of Medicine, New York, NY, USA Department of Medicine, New York University School of Medicine, New York, NY, USA c Department of Medicine, Medstar Georgetown University Hospital, Medstar Heart Institute, 3800 Reservoir Rd, NW, 5PHC, Washington, DC 20007, USA b
article info
abstract
Article history:
Aneurysms of the branches of the coronary arteries are rare. We report a case of a right
Received 12 October 2013
coronary artery aneurysm with aneurysmal dilation and thrombosis of the sinoatrial nodal
Received in revised form
branch presenting as a right atrial mass. The patient underwent multiple imaging evalu-
12 December 2013
ations before coronary CT angiography diagnosed aneurysm and thrombosis of the sino-
Accepted 16 December 2013
atrial nodal branch. ª 2014 Society of Cardiovascular Computed Tomography. All rights reserved.
Keywords: Cardiovascular computed tomography Coronary artery aneurysm Cardiac mass Multimodality imaging Magnetic resonance imaging Echocardiography
A 65-year-old woman with chest pain underwent coronary angiography that showed an enlarged right coronary artery (RCA), no obstructive coronary artery disease, and possible aneurysm in the sinus of Valsalva (Fig. 1A). Echocardiography showed dilated RCA and right atrial mass suggestive of but not definitive for lipomatous hypertrophy, given its presence on only 1 side of the interatrial septum (Fig. 1B; supplementary Movie 1). She was referred for cardiac magnetic resonance (MR) imaging for further characterization of the mass but was lost to follow-up. Cardiac MR performed 2 years later showed
proximal RCA aneurysm and a serpentine, nonenhancing structure that coursed posteriorly along the interatrial septum and posterior right atrium (Fig. 1C,D; supplementary Movie 2). Coronary CT angiogram confirmed proximal RCA aneurysm and delineated aneurysm and thrombosis with peripheral calcification of the sinoatrial nodal branch which was noted to arise from the posterior aspect of the RCA (Fig. 2). Because the patient was asymptomatic, no intervention was undertaken. Coronary artery aneurysms are rare, occurring in 0.3% to 4.9 % of patients undergoing coronary angiography,1 with
Conflict of interest: The authors report no conflict of interest. * Corresponding author. E-mail address: [email protected] (M.B. Srichai). 1934-5925/$ e see front matter ª 2014 Society of Cardiovascular Computed Tomography. All rights reserved. http://dx.doi.org/10.1016/j.jcct.2013.12.015
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J o u r n a l o f C a r d i o v a s c u l a r C o m p u t e d T o m o g r a p h y 8 ( 2 0 1 4 ) 8 5 e8 7
Fig. 1 e (A) X-ray coronary angiography RAO projection shows aneurysm of the proximal RCA with possible aneurysmal involvement of the sinus of Valsalva (asterisk); patent and normal caliber distal RCA. (B) Echocardiogram in apical 4-chamber view shows prominence of the right side of the posterior portion of the interatrial septum (arrow). (C) Steady state free precession gradient echo cine CMR image in 4-chamber view shows thickening along the right atrial posterior wall and interatrial septum (arrow). (D) After contrast, inversion recovery 4-chamber CMR image shows a tubular serpentine nonenhancing structure (arrow) that appears to arise from the proximal RCA and courses posteriorly to the interatrial septum and posterior right atrium where it assumes a rounded shape. CMR, cardiac magnetic resonance; RAO, right anterior oblique; RCA, right coronary artery. sinoatrial nodal artery aneurysms extremely rare.2 Atherosclerosis remains the most common cause of coronary artery aneurysms although they are also associated with congenital malformations, connective tissue disorders, vasculitis, infectious causes, trauma, and neoplasms.3 Coronary CT angiography can provide precise information about characteristics of coronary artery aneurysms such as diameter, length, shape, number, and associated stenoses. In addition 3-dimensional evaluation helps to delineate the anatomic location and relationship to surrounding structures.4 In children or in patients for whom there is concern for radiation exposure, echocardiography may be useful for evaluating proximal coronary segments, but coronary MR angiography is often the alternative imaging test capable of providing similar information to coronary CT angiography.4 Management is variable with surgery typically considered for aneurysms 3 to 4 times the size of the reference vessel, when there are progressive symptoms despite medical management or when associated complications such as fistula formation occur.2,3,5 After multiple imaging modalities, our patient’s condition was diagnosed by coronary CT angiography as thrombosed aneurysm of the sinoatrial nodal branch. She was managed medically and underwent workup for vasculitis and connective tissue disorders.
Supplementary data Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.jcct.2013.12.015.
references
1. Abou Eid G, Lang-Lazdunski L, Hvass U, et al. Management of giant coronary artery aneurysm with fistulization into the right atrium. Ann Thorac Surg. 1993;56:372e374. 2. Kim SH, Jang IS, Ouck C, et al. Giant atherosclerotic aneurysm of the sinoatrial nodal artery. J Thorac Cardiovasc Surg. 1997;114:280e282. 3. John LC, Hornick P, Davies DW, Banim SO, Rees GM. The role of surgery in management of solitary coronary artery aneurysm. Eur J Cardiothorac Surg. 1991;5:440e441. 4. Diaz-Zamudio M, Bacilio-Perez U, Herrera-Zarza MC, et al. Coronary artery aneurysms and ectasia: role of coronary CT angiography. Radiographics. 2009;29:1939e1954. 5. Koito R, Oku T, Satoh H, et al. Right ventricular myocardial infarction and late cardiac tamponade due to right coronary artery aneurysm: a case report. Jpn J Surg. 1990;20:463e467.
J o u r n a l o f C a r d i o v a s c u l a r C o m p u t e d T o m o g r a p h y 8 ( 2 0 1 4 ) 8 5 e8 7
87
Fig. 2 e Coronary CT angiogram. (A) Three-dimensional volume-rendered image shows proximal dilation of the RCA (*) with normal caliber vessel distally. The right heart chambers are not well opacified, but there is evidence of a calcified mass (arrow) that is posterior to the RCA. (B) Multiplanar reformatted axial view shows proximal RCA aneurysm (*). (C) Multiplanar reformatted image show aneurysmal dilation and thrombosis with peripheral calcification of the sinoatrial nodal branch (arrow). (D) Thin maximum intensity projection image shows thrombosed sinoatrial nodal branch (arrow) arising from the posterior aspect of the proximal RCA (*). Ao, aorta; LA, left atrium; LV, left ventricle; RCA, right coronary artery.
