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CARDIOVASCULAR ANESTHESIOLOGY

An Unusual Giant Right Coronary Artery Aneurysm Resembles an Intracardiac Mass

Estibaliz Alomar-Melero, MD^*, Tomas D. Martin, MD, Gregory M. Janelle, MD, and Yong G. Peng, MD, PhD^*

From the *Division of Cardiothoracic Anesthesia, Department of Surgery, Division of Thoracic and Cardiovascular Surgery, and Department of Anesthesiology, Division of Cardiovascular Anesthesiology, University of Florida College of Medicine, Gainesville, Florida.

Address correspondence to Yong G. Peng, MD, PhD, Department of Anesthesiology, University of Florida College of Medicine, PO Box 100254, 1600 SW Archer Rd., Gainesville, FL 32610-0254. Address e-mail to ypeng{at}anest.ufl.edu.

A 49-yr-old man with a history of Job’s Syndrome (Hyper IgE Syndrome), an immunologic disorder characterized by recurrent infections and connective tissue disorders, was referred to our institution for evaluation of a saccular aneurysm of the distal aortic arch and proximal descending thoracic aorta. After multiple cardiac imaging studies, including cardiac catheterization, transthoracic echocardiography, and magnetic resonance imaging, the diagnosis of an aortic root aneurysm was confirmed. In addition, a 5 x 4.5 cm right atrial rounded and homogenic mass was detected, occupying two-thirds of the right atrium and receiving feeding vessels from the right coronary artery (RCA). These findings suggested that this mass was most likely an angiosarcoma. In addition to the above findings, the imaging studies also showed diffuse aneurysmal coronary disease throughout the entire coronary bed.

The patient was scheduled for resection of the right atrial tumor, RCA bypass, and aortic root aneurysm repair. After an uneventful anesthetic induction, a transesophageal echocardiogram (TEE) confirmed a right atrial homogenic mass with a well organized capsule attached to the anterolateral wall of the atrium (Fig. 1, Video Clip 1; please see video clip available at www.anesthesia-analgesia.org). It was difficult to determine whether it was a tumor or a thrombus. Upon opening the pericardium, a giant RCA aneurysm was noted (Fig. 2, Video Clip 2; please see video clip available at www.anesthesia-analgesia.org). The findings were secondary to extrinsic compression of the right atrium by the giant and thrombosed RCA aneurysm. A RCA bypass was performed after the aneurysm excision. The aortic root aneurysm was repaired, and the patient was transferred to the intensive care unit in stable condition.

View larger version (36K): [in this window] [in a new window]   Figure 1. Partial mid-esophageal four-chamber view with primary focus on the right side of the heart demonstrating a 5 x 4.5 cm thrombosed RCA aneurysm causing extrinsic compression of the right atrium. RA = right atrium; RV = left atrium; RCA = right coronary artery.

View larger version (105K): [in this window] [in a new window]   Figure 2. Surgical view of the giant thrombosed right coronary artery aneurysm.

The diagnosis of coronary artery aneurysms can be difficult to establish despite multiple cardiac imaging studies, including angiography, magnetic resonance imaging, transthoracic echocardiography, and TEE.1,2 In certain cases, an accurate diagnosis is not made until surgery.1,2 Even with powerful imaging studies, the initial appearance of a cardiac mass can be misleading.2 Multiple reports have suggested that the differential diagnosis of a cardiac mass should include thrombus, tumors (primary or metastatic), pseudoaneurysms, saphenous vein graft aneurysms, and pericardial cysts.1,3 In our case, a coronary artery aneurysm mimicked a cardiac mass on multiple imaging modalities, including TEE. This case is another example of why coronary artery aneurysms should also be included in the differential diagnosis of an intracardiac mass.1

Footnotes

This article has supplementary material on the Web site: www.anesthesia-analgesia.org.

Accepted for publication May 30, 2008.

Supported by Institutional and/or Departmental Funds.

Reprints will not be available from the author.

REFERENCES

1. Anfinsen OG, Aaberge L, Geiran O, Smith HJ, Aakhus S. Coronary artery aneurysms mimicking cardiac tumor. Eur J Echocardiogr 2004;5:308–12[Abstract/Free Full Text]
2. Gottesfeld S, Makaryus AN, Singh B, Kaplan B, Stephen B, Steinberg B, Graver LM, Rosen SE. Thrombosed right coronary artery aneurysm presenting as a myocardial mass. J Am Soc Echocardiogr 2004;17:1319–22[Web of Science][Medline]
3. Grandmougin D, Croisille P, Robin C, Peoc’h M, Barral X. Giant coronary artery aneurysm mimicking a compressive cardiac tumor: Imaging features and operative strategy. Cardiovasc Pathol 2005;14:272–5[Web of Science][Medline]

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This Article Full Text (PDF) Echo Loops Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Web of Science (2) Citing Articles via Google Scholar Google Scholar Articles by Alomar-Melero, E. Articles by Peng, Y. G. Search for Related Content PubMed PubMed Citation Articles by Alomar-Melero, E. Articles by Peng, Y. G. Related Collections Cardiovascular Heart Monitoring (Cardiac) Echo Rounds Video Clip