Multimodality Imaging of Giant Right Coronary Aneurysm and Postsurgical Coronary Artery Inflammation

Abstract

A 52-year-old former recreational marathon runner with a history of permanent atrial fibrillation was referred to our institution because of fatigue and shortness of breath. His 12-lead ECG indicated atrial fibrillation with incomplete right bundle-branch block and inferolateral T-wave inversions ( Figure 1). The chest x-ray showed an abnormal structure with a circular silhouette at the projection of the right atrium in the anterior-posterior view (Figure 2). Transthoracic echocardiography revealed a vascular tubular structure adjacent to the atrioventricular groove ( Figure 3A and 3B and Movies I and II in the online-only Data Supplement). Subsequently, we performed a coronary computed tomography angiography (CCTA) using a 256-slice multidetector-row CT (Philips Brilliance iCT, Best, The Netherlands) with a tube voltage of 100 kV and a tube current of 300 mA. Because of the atrial fibrillation (mean heart rate, 57 bpm; range, 45-110 bpm), an arrhythmia detection algorithm was used during the prospective ECG-triggered image acquisition. The CCTA depicted a normal left coronary system with no signs of atherosclerosis. The ostium of the right coronary artery (RCA) was dilated (10×8 mm), and the proximal segment of the vessel formed a giant aneurysm ( Figure 4A and 4B). The location of the aneurysm was noted to be anterior to the right atrium, adjacent to the atrioventricular groove, and its size measured 62×60×86 mm ( Figure 4D-4F). Distal to the aneurysm, the extremely tortuous RCA remained enlarged (12-14 mm) and showed a fistulous communication with the coronary sinus ( Figure 4C). The length of the whole RCA was ≈80 cm along its centerline. Subsequent invasive coronary angiography confirmed the CCTA findings (Movies III and IV in the online-only Data Supplement). Surgery was performed to repair the RCA and to stop the shunt. During the surgical procedure, the aneurysm was resected ( Figure 5A-5C), the RCA was reimplanted into the aorta ( Figure 5D), and the fistula was ligated at the orifice of the coronary sinus. Because of the permanent atrial fibrillation, the maze procedure and left auricle ligation were also performed, but restoration of the sinus rhythm was unsuccessful. The postoperative observation period was uneventful. At the 6-week regular follow-up examination, the patient was asymptomatic with normofrequent atrial fibrillation. Five months after the surgical procedure, the patient presented with cough, night sweats, and low-grade fever, which had persisted over the previous week. The chest x-ray was unremarkable ( Figure 6A). The urgent chest CT examination showed lesions with central low attenuation and ring-like enhancement behind the left ventricle, which raised the possibility of an abscess ( Figure 6B). Cardiac magnetic resonance imaging (1.5 T, Philips Achieva, Philips Medical Systems, Best, The Netherlands) demonstrated mildly elevated left and right ventricular volumes with preserved left and right systolic ventricular function (both left ventricular and right ventricular ejection fraction...

Predicting the cardiac toxicity of drugs using a novel multiscale exposure–response simulator

“…In October 1999, a new class III antiarrhythmic drug, dofetilide, was approved for treatment of atrial fibrillation in the United States (Pfizer, 2011). Atrial fibrillation, the most common sustained cardiac arrhythmia, affects more than 6 million people in the United States (American Heart Association, 2015) and 33 million worldwide (Chugh, Havmoeller, Narayanan, Singh, Rienstra, Benjamin, Gillum, Kim, McAnulty, Zheng, Forouzanfar, Naghavi, Mensah, Ezzati, and Murray, 2014). Dofetilide cardioverts persistent atrial fibrillation to sinus rhythm by selectively blocking the rapid delayed rectifier potassium current, which slows the efflux of potassium ions, reduces the repolarization rate of the cell, and widens the plateau of the action potential (Mirams, Cui, Sher, Fink, Cooper, Heath, McMahon, Gavaghan, and Noble, 2011).…”

Daily Communal Coping in Couples With Type 2 Diabetes: Links to Mood and Self-Care

“…A substantial number of adults in the USA are living with a chronic illness. For example, 85.6 million people are living with some form of cardiovascular disease or the after effects of a stroke (1), 14.5 million people have a history of cancer or are currently living with cancer (2), and 21.0 million people have been diagnosed with diabetes (3). The diagnosis of a chronic illness can be a major stressor, one with which both the patient and their social network must learn to cope with for a long period of time.…”

Understanding Primary Care Provider Attitudes and Behaviors Regarding Cardiovascular Disease Risk and Diabetes Prevention in the Northern Midwest

“…The situation is likely exacerbated in rural areas, where diabetes incidence is about 17% higher than in urbanized regions (2). Also, compared with urban communities, rural communities continue to have higher rates of coronary heart disease (3), the foremost cause of death for adults in the United States (4).…”