- Email: [email protected]
An 81-Year-Old Man With an Abnormal Right-Sided Heart Shadow on Chest Radiograph
[
Pulmonary, Critical Care, and Sleep Pearls
]
An 81-Year-Old Man With an Abnormal Right-Sided Heart Shadow on Chest Radiograph Rahman Shah, MD; M. Rehan Khan, MD; Tai-Hwang M. Fan, MD, PhD; Genina Ruff, RCS; and Kodangudi B. Ramanathan, MD
An 81-year-old man presented with a 1-week history of dry cough. He also complained of mild dyspnea, wheezing, and low-grade fever. He denied hemoptysis, fever, rashes, or chest pain. The patient’s medical history included coronary artery bypass surgery, hypertension, gastroesophageal reflux disease, and COPD. The patient was a retired welder and an ex-smoker. CHEST 2015; 147(2):e52-e55
Physical Examination Findings The patient was afebrile, and vital signs were all within normal limits. Oxygen saturation was 97% on room air. Heart examination findings were normal, with no murmurs or rubs appreciated. Pulmonary examination demonstrated few expiratory wheezes bilaterally. The patient’s abdomen was nontender, with no organomegaly. There was no digital clubbing or peripheral edema. His skin was intact without nodules or rashes.
by contrast material compatible with a vascular structure (Fig 2B, Video 2). Follow-up chest CT scan with contrast indicated a partially thrombosed (Fig 3, double arrow) vascular structure that measured approximately 6.9 3 6.7 cm.
Diagnostic Studies Results of a basic metabolic panel, liver function tests, and CBC counts with differential were all within normal limits. Chest radiography, however, revealed a localized bulge at the right-side heart border suspicious for right ventricular aneurysm (Fig 1, arrows); thus, the patient next underwent transthoracic echocardiography and contrast echocardiography. Transthoracic echocardiography indicated normal right ventricular chamber size and function but showed a 6.1 3 5.6 cm round mass external to the right atrium (Fig 2A, Video 1). Contrast echocardiography indicated that the mass was enhanced
Manuscript received June 9, 2014; revision accepted July 17, 2014. AFFILIATIONS: From the Section of Cardiology (Drs Shah, Fan, and Ramanathan), School of Medicine, University of Tennessee, Memphis, TN; Veterans Affairs Medical Center (Drs Shah, Fan, and Ramanathan and Ms Ruff), Memphis, TN; and the Department of Radiology (Dr Khan), School of Medicine, Virginia Commonwealth University, Richmond, VA.
e52 Pulmonary, Critical Care, and Sleep Pearls
Figure 1 – Chest radiograph showing a localized bulge at the right-side heart border (arrows).
Rahman Shah, MD, Veterans Affairs Medical Center, 1030 Jefferson Ave, Memphis, TN 38104; e-mail: shahcardiology@ yahoo.com © 2015 AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.14-1393 CORRESPONDENCE TO:
[
147#2 CHEST FEBRUARY 2015
]
Figure 2 – A, Echocardiograph showing a mass external to the RA (arrows). B, Contrast echocardiography showing a vascular structure (arrows). RA 5 right atrium; RV 5 right ventricle.
Figure 3 – Chest CT scan with contrast showing a partially thrombosed (double arrow) right coronary artery aneurysm (arrows). See Figure 2 legend for expansion of abbreviation.
What procedure should be performed next? What is the diagnosis?
journal.publications.chestnet.org
e53
Answer: Selective right coronary artery angiography confirmed the diagnosis (Video 3) Diagnosis: Asymptomatic giant right coronary artery aneurysm Discussion Coronary artery aneurysms (CAAs) are rare, with a reported incidence ranging from 0.15% to 4.9%, whereas giant CAAs (diameter . 20 mm) are even rarer. Atherosclerosis accounts for the majority of CAAs in adults, whereas Kawasaki disease is responsible for most cases in children. The natural history of CAA is largely unknown, as most reports in the literature involve only a small number of patients with relatively short-term follow-up. However, reported complications include thrombosis, embolization, rupture, fistula, vasospasm, and mass effect. Such a thrombus is prone to enlarge, which may cause occlusion of the aneurysm, or to dislodge and embolize to major distal vessels or the coronary microcirculation, leading to acute coronary syndrome. In cases with fistula formation, complications are congestive heart failure due to high output status and coronary artery steal phenomenon due to reduction in myocardial blood flow distal to the site of the coronary artery fistula. Furthermore, fistulae can cause flow turbulence and roughen the endothelium, leading to bacterial colonization and endocarditis. Hemoptysis, hemothorax, hemodynamic collapse, and death secondary to rupture of a giant CAA have also been reported. Finally, a mass effect on adjacent anatomic structures in the chest, causing compression of the cardiac chambers and the pulmonary artery, has also been reported. In addition to the native graft aneurysm, true and pseudoaneurysms of saphenous venous grafts (SVGs) can develop in patients with a bypass graft. SVG pseudoaneurysms usually occur at the proximal or distal anastomotic site and are believed to be caused by tension on the graft anastomosis, leading to suture rupture, or from erroneous placement of a suture. On the other hand, true aneurysms of SVGs have been associated with atherosclerosis, hyperlipidemia, and weakness in the graft wall near the valve. True aneurysms most often present after several years and can be as large as 8 cm. Occasionally, SVG aneurysms are detected incidentally as an anterior mediastinal mass on chest radiography, but they are more often found as a result of a clinical event. Reported complications
e54 Pulmonary, Critical Care, and Sleep Pearls
mirror those of native CAAs, including thrombosis, embolization, rupture, and fistula formation. The best management strategy for CAA is unclear. Treatment to date has been based primarily on anecdotal reports because no controlled trials of therapy exist. However, depending on the symptoms, etiology, and associated lesions, medical treatment (antiplatelet agent, anticoagulation), stent implantation, or surgical exclusion of the aneurysm using resection or a ligation technique have been described. Surgical treatment is offered for CAAs accompanied by obstructive coronary artery disease. Surgery has also been advocated to prevent potential complications associated with very large CAAs. Clinical Course
Surgical repair of the aneurysm was recommended to the patient because of the size of the CAA. However, the patient declined this intervention because he was asymptomatic and concerned about the risk associated with repeat open heart surgery in the presence of his other medical conditions. His cough, wheezing, and dyspnea resolved after 1 week of conventional therapy for a COPD flare.
Clinical Pearls 1. Atherosclerosis accounts for the majority of CAAs in adults, whereas Kawasaki disease is responsible for most cases in children. 2. Occasionally, giant CAAs are detected incidentally as an anterior mediastinal mass on chest radiography, but they are more often found as a result of clinical events, such as chest pain and acute coronary syndrome. 3. Reported complications of giant CAAs include thrombosis, embolization, rupture, fistula, vasospasm, and mass effect on adjacent anatomic structures in the chest, causing compression of the cardiac chambers and the pulmonary artery. 4. The best management strategy for CAA is unclear. 5. Surgical treatment is offered to prevent potential complications when CAAs are accompanied by obstructive coronary artery disease or when they are very large.
Acknowledgments Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/ organizations whose products or services may be discussed in this article. Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.
[
147#2 CHEST FEBRUARY 2015
]
Additional information: The Videos can be found in the Multimedia section of the online article.
Li D, Wu Q, Sun L, et al. Surgical treatment of giant coronary artery aneurysm. J Thorac Cardiovasc Surg. 2005;130(3):817-821.
Syed M, Lesch M. Coronary artery aneurysm: a review. Prog Cardiovasc Dis. 1997;40(1):77-84.
Topaz O, Rutherford MS, Mackey-Bojack S, et al. Giant aneurysms of coronary arteries and saphenous vein grafts: angiographic findings and histopathological correlates. Cardiovasc Pathol. 2005;14(6): 298-302.
Wight JN Jr, Salem D, Vannan MA, et al. Asymptomatic large coronary artery saphenous vein bypass graft aneurysm: a case report and review of the literature. Am Heart J. 1997;133(4):454-460.
Ramos SG, Mata KM, Martins CC, Martins AP, Rossi MA. Giant right coronary artery aneurysm presenting as a paracardiac mass. Cardiovasc Pathol. 2008;17(5):329-333.
Suggested Readings
journal.publications.chestnet.org
e55
Pulmonary, Critical Care, and Sleep Pearls
]
An 81-Year-Old Man With an Abnormal Right-Sided Heart Shadow on Chest Radiograph Rahman Shah, MD; M. Rehan Khan, MD; Tai-Hwang M. Fan, MD, PhD; Genina Ruff, RCS; and Kodangudi B. Ramanathan, MD
An 81-year-old man presented with a 1-week history of dry cough. He also complained of mild dyspnea, wheezing, and low-grade fever. He denied hemoptysis, fever, rashes, or chest pain. The patient’s medical history included coronary artery bypass surgery, hypertension, gastroesophageal reflux disease, and COPD. The patient was a retired welder and an ex-smoker. CHEST 2015; 147(2):e52-e55
Physical Examination Findings The patient was afebrile, and vital signs were all within normal limits. Oxygen saturation was 97% on room air. Heart examination findings were normal, with no murmurs or rubs appreciated. Pulmonary examination demonstrated few expiratory wheezes bilaterally. The patient’s abdomen was nontender, with no organomegaly. There was no digital clubbing or peripheral edema. His skin was intact without nodules or rashes.
by contrast material compatible with a vascular structure (Fig 2B, Video 2). Follow-up chest CT scan with contrast indicated a partially thrombosed (Fig 3, double arrow) vascular structure that measured approximately 6.9 3 6.7 cm.
Diagnostic Studies Results of a basic metabolic panel, liver function tests, and CBC counts with differential were all within normal limits. Chest radiography, however, revealed a localized bulge at the right-side heart border suspicious for right ventricular aneurysm (Fig 1, arrows); thus, the patient next underwent transthoracic echocardiography and contrast echocardiography. Transthoracic echocardiography indicated normal right ventricular chamber size and function but showed a 6.1 3 5.6 cm round mass external to the right atrium (Fig 2A, Video 1). Contrast echocardiography indicated that the mass was enhanced
Manuscript received June 9, 2014; revision accepted July 17, 2014. AFFILIATIONS: From the Section of Cardiology (Drs Shah, Fan, and Ramanathan), School of Medicine, University of Tennessee, Memphis, TN; Veterans Affairs Medical Center (Drs Shah, Fan, and Ramanathan and Ms Ruff), Memphis, TN; and the Department of Radiology (Dr Khan), School of Medicine, Virginia Commonwealth University, Richmond, VA.
e52 Pulmonary, Critical Care, and Sleep Pearls
Figure 1 – Chest radiograph showing a localized bulge at the right-side heart border (arrows).
Rahman Shah, MD, Veterans Affairs Medical Center, 1030 Jefferson Ave, Memphis, TN 38104; e-mail: shahcardiology@ yahoo.com © 2015 AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.14-1393 CORRESPONDENCE TO:
[
147#2 CHEST FEBRUARY 2015
]
Figure 2 – A, Echocardiograph showing a mass external to the RA (arrows). B, Contrast echocardiography showing a vascular structure (arrows). RA 5 right atrium; RV 5 right ventricle.
Figure 3 – Chest CT scan with contrast showing a partially thrombosed (double arrow) right coronary artery aneurysm (arrows). See Figure 2 legend for expansion of abbreviation.
What procedure should be performed next? What is the diagnosis?
journal.publications.chestnet.org
e53
Answer: Selective right coronary artery angiography confirmed the diagnosis (Video 3) Diagnosis: Asymptomatic giant right coronary artery aneurysm Discussion Coronary artery aneurysms (CAAs) are rare, with a reported incidence ranging from 0.15% to 4.9%, whereas giant CAAs (diameter . 20 mm) are even rarer. Atherosclerosis accounts for the majority of CAAs in adults, whereas Kawasaki disease is responsible for most cases in children. The natural history of CAA is largely unknown, as most reports in the literature involve only a small number of patients with relatively short-term follow-up. However, reported complications include thrombosis, embolization, rupture, fistula, vasospasm, and mass effect. Such a thrombus is prone to enlarge, which may cause occlusion of the aneurysm, or to dislodge and embolize to major distal vessels or the coronary microcirculation, leading to acute coronary syndrome. In cases with fistula formation, complications are congestive heart failure due to high output status and coronary artery steal phenomenon due to reduction in myocardial blood flow distal to the site of the coronary artery fistula. Furthermore, fistulae can cause flow turbulence and roughen the endothelium, leading to bacterial colonization and endocarditis. Hemoptysis, hemothorax, hemodynamic collapse, and death secondary to rupture of a giant CAA have also been reported. Finally, a mass effect on adjacent anatomic structures in the chest, causing compression of the cardiac chambers and the pulmonary artery, has also been reported. In addition to the native graft aneurysm, true and pseudoaneurysms of saphenous venous grafts (SVGs) can develop in patients with a bypass graft. SVG pseudoaneurysms usually occur at the proximal or distal anastomotic site and are believed to be caused by tension on the graft anastomosis, leading to suture rupture, or from erroneous placement of a suture. On the other hand, true aneurysms of SVGs have been associated with atherosclerosis, hyperlipidemia, and weakness in the graft wall near the valve. True aneurysms most often present after several years and can be as large as 8 cm. Occasionally, SVG aneurysms are detected incidentally as an anterior mediastinal mass on chest radiography, but they are more often found as a result of a clinical event. Reported complications
e54 Pulmonary, Critical Care, and Sleep Pearls
mirror those of native CAAs, including thrombosis, embolization, rupture, and fistula formation. The best management strategy for CAA is unclear. Treatment to date has been based primarily on anecdotal reports because no controlled trials of therapy exist. However, depending on the symptoms, etiology, and associated lesions, medical treatment (antiplatelet agent, anticoagulation), stent implantation, or surgical exclusion of the aneurysm using resection or a ligation technique have been described. Surgical treatment is offered for CAAs accompanied by obstructive coronary artery disease. Surgery has also been advocated to prevent potential complications associated with very large CAAs. Clinical Course
Surgical repair of the aneurysm was recommended to the patient because of the size of the CAA. However, the patient declined this intervention because he was asymptomatic and concerned about the risk associated with repeat open heart surgery in the presence of his other medical conditions. His cough, wheezing, and dyspnea resolved after 1 week of conventional therapy for a COPD flare.
Clinical Pearls 1. Atherosclerosis accounts for the majority of CAAs in adults, whereas Kawasaki disease is responsible for most cases in children. 2. Occasionally, giant CAAs are detected incidentally as an anterior mediastinal mass on chest radiography, but they are more often found as a result of clinical events, such as chest pain and acute coronary syndrome. 3. Reported complications of giant CAAs include thrombosis, embolization, rupture, fistula, vasospasm, and mass effect on adjacent anatomic structures in the chest, causing compression of the cardiac chambers and the pulmonary artery. 4. The best management strategy for CAA is unclear. 5. Surgical treatment is offered to prevent potential complications when CAAs are accompanied by obstructive coronary artery disease or when they are very large.
Acknowledgments Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/ organizations whose products or services may be discussed in this article. Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.
[
147#2 CHEST FEBRUARY 2015
]
Additional information: The Videos can be found in the Multimedia section of the online article.
Li D, Wu Q, Sun L, et al. Surgical treatment of giant coronary artery aneurysm. J Thorac Cardiovasc Surg. 2005;130(3):817-821.
Syed M, Lesch M. Coronary artery aneurysm: a review. Prog Cardiovasc Dis. 1997;40(1):77-84.
Topaz O, Rutherford MS, Mackey-Bojack S, et al. Giant aneurysms of coronary arteries and saphenous vein grafts: angiographic findings and histopathological correlates. Cardiovasc Pathol. 2005;14(6): 298-302.
Wight JN Jr, Salem D, Vannan MA, et al. Asymptomatic large coronary artery saphenous vein bypass graft aneurysm: a case report and review of the literature. Am Heart J. 1997;133(4):454-460.
Ramos SG, Mata KM, Martins CC, Martins AP, Rossi MA. Giant right coronary artery aneurysm presenting as a paracardiac mass. Cardiovasc Pathol. 2008;17(5):329-333.
Suggested Readings
journal.publications.chestnet.org
e55