© 2015, Wiley Periodicals, Inc. DOI: 10.1111/echo.12922
Echocardiography
Two Giant Right Coronary Artery Aneurysms with Fistula to the Left Ventricle: Preliminary Diagnosis by Echocardiography Yuman Li, M.D., Ph.D., Mingxing Xie, M.D., Ph.D., Xinfang Wang, M.D., Ph.D., Qing Lv, M.D., Ph.D., YaLi Yang, M.D., Ph.D., and Lin He, M.D., Ph.D., Department of Ultrasonography, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
(Echocardiography 2015;32:1053–1055) Key words: coronary artery fistula, coronary artery disease, aneurysm, echocardiography
A 51-year-old man was referred to our hospital with a cough productive of white sputum for two weeks. On auscultation, a grade 3/6 diastolic murmur was detected at the apex of heart. Transthoracic echocardiography showed that a giant right coronary artery (RCA) aneurysm, approximately 12 9 11 cm in size, compressing the right atrium and right ventricle, was found in
the proximal portion of the vessel (Fig. 1A–C). Another giant RCA aneurysm, approximately 5 9 4 cm in size, was identified in the distal portion of the vessel (Fig. 1D–E). There was a 1.8-cm fistula between the distal part of the RCA and the basal inferolateral wall of the left ventricle (LV) (Fig. 1E). Color Doppler imaging revealed abnormal turbulent flow originating just beneath the
Figure 1. Preoperative transthoracic echocardiography for RCA to left ventricle fistula with two giant coronary artery aneurysms in a 51-year-old man. A, B. Two-dimensional echocardiography and color Doppler imaging show a dilated ostium of the RCA and a giant RCA aneurysm located in the proximal portion of the vessel. C. A giant RCA aneurysm compresses the RA and RV. D. Twodimensional echocardiography in the subcostal view reveals a markedly dilated, tortuous RCA and another giant RCA aneurysm located in the distal portion of the vessel. E, F. Two-dimensional echocardiography and color Doppler imaging show a dilated RCA draining into the basal inferolateral wall of the LV; the arrow shows the draining site. An = aneurysm; Ao = aorta; LA = left atrium; LV = left ventricle; RV = right ventricle; RCA = right coronary artery; MV = mitral valve. Funding sources: This work was supported by The National Natural Science Foundation of China 81401432. Address for correspondence and reprint: Mingxing Xie, M.D., Ph.D., Department of Ultrasonography, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277# Jiefang Ave, Wuhan 430022, China. Fax: +86-27-85726386; E-mail: [email protected]
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Figure 2. Computed tomography angiography of coronary arteries, coronary artery angiography, intraoperative photograph, and postoperative echocardiography images for RCA to left ventricle fistula with two giant coronary artery aneurysms in a 51year-old man. A, B. Computed tomography angiography of coronary arteries shows two giant coronary artery aneurysms with enlarged and tortuous RCA that is draining into the LV. C, D. The coronary artery angiography shows a giant RCA aneurysm located in the proximal portion of the vessel (C) and normal left coronary artery (D). E, F. Intraoperative photographs (external view) of the giant RCA aneurysm located in the proximal portion of the vessel. Intraoperative photographs were permitted from this patient. G, H. Postoperative transthoracic echocardiography shows successful closure of a giant RCA aneurysm with a fistula to the LV. Color Doppler imaging does not reveal the existence of a residual shunt (arrow). An = aneurysm; RCA = right coronary artery; LV = left ventricle; Ao = aorta; LA = left atrium.
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lateral aspect of the mitral annulus at diastole (Fig. 1F). A computed tomography angiography of coronary arteries confirmed the presence of two giant aneurysms located in the proximal and distal portions of the RCA, associated with a fistula draining into the LV (Fig. 2A,B). The coronary artery angiography showed a giant RCA aneurysm located in the proximal portion of the vessel (Fig. 2C) and the normal left coronary artery (Fig. 2D). The patient underwent coronary artery surgery. A giant RCA aneurysm located in the proximal portion of the vessel, approximately 12 9 12 cm in size, was exposed (Fig. 2E,F). The operation confirmed the preoperative diagnosis. The patient was treated successfully by closure of the fistula and the orifice of the RCA, and coronary artery bypass grafting. The postoperative course of this patient was uneventful. Postoperative echocardiography images of this patient revealed successful closure of the congenital giant RCA aneurysm with a LV fistula (Fig. 2G,H). The study was approved by an institutional review committee, and this patient gave informed consent. Coronary artery fistula (CAF) is a relatively rare condition, occurring in 0.002% of the general
population.1 Approximately 55–65% of congenital CAFs arise from the RCA and usually drain into the right heart;2 fistulas of the RCA into the left heart are still considerably rare. Coronary artery aneurysm is also an uncommon disease, with an incidence of 1.5% to 5%.3 An aneurysm larger than 20 mm in diameter is called a giant coronary artery aneurysm.4 Such a RCA-to-LV fistula with two giant RCA aneurysms is even rarer. In our case, transthoracic echocardiography was very useful for the diagnosis of RCA-to-LV fistula complicated with two giant coronary artery aneurysms. References 1. Leitman M, Hirsch R, Rosenblatt S, et al: Diagnosis and percutaneous closure of a large coronary fistula. Echocardiography 2011;28:248–252. 2. Fernandes ED, Kadivar H, Hallman GL, et al: Congenital malformations of the coronary arteries: the Texas Heart Institute experience. Ann Thorac Surg 1992;54:732–740. 3. Gottesfeld S, Makaryus AN, Singh B, et al: Thrombosed right coronary artery aneurysm presenting as a myocardial mass. J Am Soc Echocardiogr 2004;17:1319–1322. 4. Li D, Wu Q, Sun L, et al: Surgical treatment of giant coronary artery aneurysm. J Thorac Cardiovasc Surg 2005;130:817–821.
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Echocardiography
Two Giant Right Coronary Artery Aneurysms with Fistula to the Left Ventricle: Preliminary Diagnosis by Echocardiography Yuman Li, M.D., Ph.D., Mingxing Xie, M.D., Ph.D., Xinfang Wang, M.D., Ph.D., Qing Lv, M.D., Ph.D., YaLi Yang, M.D., Ph.D., and Lin He, M.D., Ph.D., Department of Ultrasonography, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
(Echocardiography 2015;32:1053–1055) Key words: coronary artery fistula, coronary artery disease, aneurysm, echocardiography
A 51-year-old man was referred to our hospital with a cough productive of white sputum for two weeks. On auscultation, a grade 3/6 diastolic murmur was detected at the apex of heart. Transthoracic echocardiography showed that a giant right coronary artery (RCA) aneurysm, approximately 12 9 11 cm in size, compressing the right atrium and right ventricle, was found in
the proximal portion of the vessel (Fig. 1A–C). Another giant RCA aneurysm, approximately 5 9 4 cm in size, was identified in the distal portion of the vessel (Fig. 1D–E). There was a 1.8-cm fistula between the distal part of the RCA and the basal inferolateral wall of the left ventricle (LV) (Fig. 1E). Color Doppler imaging revealed abnormal turbulent flow originating just beneath the
Figure 1. Preoperative transthoracic echocardiography for RCA to left ventricle fistula with two giant coronary artery aneurysms in a 51-year-old man. A, B. Two-dimensional echocardiography and color Doppler imaging show a dilated ostium of the RCA and a giant RCA aneurysm located in the proximal portion of the vessel. C. A giant RCA aneurysm compresses the RA and RV. D. Twodimensional echocardiography in the subcostal view reveals a markedly dilated, tortuous RCA and another giant RCA aneurysm located in the distal portion of the vessel. E, F. Two-dimensional echocardiography and color Doppler imaging show a dilated RCA draining into the basal inferolateral wall of the LV; the arrow shows the draining site. An = aneurysm; Ao = aorta; LA = left atrium; LV = left ventricle; RV = right ventricle; RCA = right coronary artery; MV = mitral valve. Funding sources: This work was supported by The National Natural Science Foundation of China 81401432. Address for correspondence and reprint: Mingxing Xie, M.D., Ph.D., Department of Ultrasonography, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277# Jiefang Ave, Wuhan 430022, China. Fax: +86-27-85726386; E-mail: [email protected]
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Figure 2. Computed tomography angiography of coronary arteries, coronary artery angiography, intraoperative photograph, and postoperative echocardiography images for RCA to left ventricle fistula with two giant coronary artery aneurysms in a 51year-old man. A, B. Computed tomography angiography of coronary arteries shows two giant coronary artery aneurysms with enlarged and tortuous RCA that is draining into the LV. C, D. The coronary artery angiography shows a giant RCA aneurysm located in the proximal portion of the vessel (C) and normal left coronary artery (D). E, F. Intraoperative photographs (external view) of the giant RCA aneurysm located in the proximal portion of the vessel. Intraoperative photographs were permitted from this patient. G, H. Postoperative transthoracic echocardiography shows successful closure of a giant RCA aneurysm with a fistula to the LV. Color Doppler imaging does not reveal the existence of a residual shunt (arrow). An = aneurysm; RCA = right coronary artery; LV = left ventricle; Ao = aorta; LA = left atrium.
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lateral aspect of the mitral annulus at diastole (Fig. 1F). A computed tomography angiography of coronary arteries confirmed the presence of two giant aneurysms located in the proximal and distal portions of the RCA, associated with a fistula draining into the LV (Fig. 2A,B). The coronary artery angiography showed a giant RCA aneurysm located in the proximal portion of the vessel (Fig. 2C) and the normal left coronary artery (Fig. 2D). The patient underwent coronary artery surgery. A giant RCA aneurysm located in the proximal portion of the vessel, approximately 12 9 12 cm in size, was exposed (Fig. 2E,F). The operation confirmed the preoperative diagnosis. The patient was treated successfully by closure of the fistula and the orifice of the RCA, and coronary artery bypass grafting. The postoperative course of this patient was uneventful. Postoperative echocardiography images of this patient revealed successful closure of the congenital giant RCA aneurysm with a LV fistula (Fig. 2G,H). The study was approved by an institutional review committee, and this patient gave informed consent. Coronary artery fistula (CAF) is a relatively rare condition, occurring in 0.002% of the general
population.1 Approximately 55–65% of congenital CAFs arise from the RCA and usually drain into the right heart;2 fistulas of the RCA into the left heart are still considerably rare. Coronary artery aneurysm is also an uncommon disease, with an incidence of 1.5% to 5%.3 An aneurysm larger than 20 mm in diameter is called a giant coronary artery aneurysm.4 Such a RCA-to-LV fistula with two giant RCA aneurysms is even rarer. In our case, transthoracic echocardiography was very useful for the diagnosis of RCA-to-LV fistula complicated with two giant coronary artery aneurysms. References 1. Leitman M, Hirsch R, Rosenblatt S, et al: Diagnosis and percutaneous closure of a large coronary fistula. Echocardiography 2011;28:248–252. 2. Fernandes ED, Kadivar H, Hallman GL, et al: Congenital malformations of the coronary arteries: the Texas Heart Institute experience. Ann Thorac Surg 1992;54:732–740. 3. Gottesfeld S, Makaryus AN, Singh B, et al: Thrombosed right coronary artery aneurysm presenting as a myocardial mass. J Am Soc Echocardiogr 2004;17:1319–1322. 4. Li D, Wu Q, Sun L, et al: Surgical treatment of giant coronary artery aneurysm. J Thorac Cardiovasc Surg 2005;130:817–821.
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