Giant aneurysms of the left main coronary artery are one of the rarest findings in cardiology, encountered in less than 0.02% of patients. The presentation is usually the same as coronary artery disease since most coronary aneurysms in the western world are associated with atherosclerosis. Here we report the first case of giant aneurysm of the left main coronary artery presenting as ventricular tachycardia with multiple shocks of the defibrillator in a 57-year-old man with heart failure. We also review the etiology, pathology, and management of coronary aneurysms

Castillo, Ricardo

Malyshev, Yury

Sahni, Sonu

Syed, Asma

Syed, Rumman A

English

The Touro College and University System

Touro Scholar Touro College of Osteopathic Medicine (New York) Publications and Research Touro College of Osteopathic Medicine (New York) 4-12-2020 Giant Left Main Coronary Artery Aneurysm Presenting as Multiple Implantable Cardioverter Defibrillator Shocks Yury Malyshev Asma Syed Ricardo Castillo Rumman A Syed Sonu Sahni Follow this and additional works at: https://touroscholar.touro.edu/tcomny_pubs  Part of the Cardiology Commons Received 03/17/2020 Review began 03/28/2020 Review ended 04/05/2020 Published 04/12/2020© Copyright 2020Malyshev et al. This is an openaccess article distributed under theterms of the Creative CommonsAttribution License CC-BY 4.0., whichpermits unrestricted use, distribution,and reproduction in any medium,provided the original author andsource are credited.Giant Left Main Coronary Artery AneurysmPresenting as Multiple ImplantableCardioverter Defibrillator ShocksYury Malyshev  , Asma Syed  , Ricardo Castillo  , Rumman A. Syed  , Sonu Sahni   1. Cardiology, Maimonides Medical Center, Brooklyn, USA 2. Cardiology, Brookdale University HospitalMedical Center, Brooklyn, USA 3. Internal Medicine, Brookdale University Hospital Medical Center,Brooklyn, USA 4. Research Medicine, New York Institute of Technology College of Osteopathic Medicine,New York, USA 5. Primary Care, Touro College of Osteopathic Medicine, New York, USACorresponding author: Yury Malyshev, yurimalish@hotmail.comAbstractGiant aneurysms of the left main coronary artery are one of the rarest findings in cardiology,encountered in less than 0.02% of patients. The presentation is usually the same as coronaryartery disease since most coronary aneurysms in the western world are associated withatherosclerosis. Here we report the first case of giant aneurysm of the left main coronary arterypresenting as ventricular tachycardia with multiple shocks of the defibrillator in a 57-year-oldman with heart failure. We also review the etiology, pathology, and management of coronaryaneurysms.Categories: Cardiology, AnatomyKeywords: coronary artery aneurysm, defibrillator shock, ventricular tachycardia, left main coronaryartery aneurysm, left main aneurysmIntroductionCoronary artery aneurysms (CAAs) are very rare clinical entities; among them giant left maincoronary artery aneurysms (LMCAAs) are exceedingly rare, encountered in less than 0.02% ofpatients [1]. Etiology of CAA varies depending on age, comorbidities and even geographicalarea. The etiology usually determines presentation and management. Herein we report aunique case of giant LMCAA in a 57-year-old man with heart failure with reduced ejectionfraction (HFrEF), who presented to our emergency department with chest pain after hisimplantable cardioverter defibrillator (ICD) fired 12 times. Urgent diagnostic catheterizationshowed giant LMCAA without signs of coronary artery disease (CAD). The patient was startedon dual antiplatelet therapy. He remained asymptomatic for more than a year. We also reviewcurrent literature on various diagnostic modalities and different management approaches ofCAAs. Case PresentationA 57-year-old man with hypertension, diabetes, obesity, and HFrEF presented with chest pain,palpitations, and syncope the day before. His ICD fired 12 times. His vitals were unremarkable.Physical examination was significant for irregular pulse. EKG showed normal sinus rhythm withfrequent premature ventricular complexes and left anterior fascicular block (Figure 1).1 2 2 3 3, 4, 5 Open Access CaseReport  DOI: 10.7759/cureus.7653How to cite this articleMalyshev Y, Syed A, Castillo R, et al. (April 12, 2020) Giant Left Main Coronary Artery AneurysmPresenting as Multiple Implantable Cardioverter Defibrillator Shocks. Cureus 12(4): e7653. DOI10.7759/cureus.7653FIGURE 1: EKG showing sinus rhythm with prematureventricular contractions and left anterior fascicular blockChest x-ray was clear. Blood work showed elevated cardiac enzymes and electrolyteabnormality, and drug screen was positive for cannabinoid (Table 1).Test ResultTroponin (ng/mL) 2.14CPK (U/L) 537pBNP (pg/mL) 1860Potassium (mEq/L) 2.8ANA NegativeAnti-dsDNA antibody (IU/mL) 1pANCA (AU/mL) <1.0C3 complement (mg/dL) 202C4 complement (mg/dL) 40Drug screen CannabinoidsTABLE 1: Significant lab resultsCPK, creatine phosphokinase; pBNP, pro-brain natriuretic peptide; ANA, antinuclear antibody; anti-dsDNA, anti-double-stranded DNAantibody; pANCA, perinuclear antineutrophil cytoplasmic antibodiesICD interrogation showed that two shocks were administered for ventricular tachycardia and 102020 Malyshev et al. Cureus 12(4): e7653. DOI 10.7759/cureus.7653 2 of 7shocks were inappropriate due to electromagnetic interference on the lead. Echocardiogramrevealed ejection fraction of 10%-15% with diffuse hypokinesis (Video 1).VIDEO 1: Echocardiogram showing severely reduced leftventricular systolic function, ejection fraction of 10%-15%, anddiffuse hypokinesisView video here: https://www.youtube.com/watch?v=XIyaB9tamJ8Urgent cardiac catheterization showed no evidence of occlusive CAD. There was however alarge saccular LMCAA involving the ostium of the left anterior descending (LAD), leftcircumflex (LCX), and ramus intermedius arteries. The size of the aneurysm was measured to be37.4 mm x 20 mm (Figure 2, Video 2). Autoimmune workup was negative (Table 1).FIGURE 2: Giant aneurysm of the left main coronary aneurysmA: right anterior oblique cranial view; B: right anterior oblique caudal view 2020 Malyshev et al. Cureus 12(4): e7653. DOI 10.7759/cureus.7653 3 of 7VIDEO 2: Angiogram showing giant aneurysm of the left maincoronary arteryView video here: https://www.youtube.com/watch?v=A8vu-i-HNAgThe patient was started on dual antiplatelet therapy with aspirin and clopidogrel. CT surgeryevaluated the patient, but did not recommend intervention. The patient had successfulimplantation of a cardioverter defibrillator during the same admission. He was seen in ED oneyear later with suspicion for pulmonary embolism. CT chest angiogram showed LMCAA to be1.5 cm in diameter (Figure 3).FIGURE 3: CT chest showing left main coronary arteryaneurysm (white arrow)A: transverse plane; B: coronal planeTwo months after the ED visit, he was seen in the clinic symptom free and ICD was functioningwell. DiscussionCAA is a segment of the artery with width greater than length and diameter greater thandiameter of a normal adjacent segment or 1.5 times larger than the largest coronary vessel(Figure 4) [2,3].2020 Malyshev et al. Cureus 12(4): e7653. DOI 10.7759/cureus.7653 4 of 7FIGURE 4: Schematic representation of a true coronaryaneurysmd, diameterCAAs are classified as follows. Wall composition: true aneurysms have all three vessel walllayers; pseudoaneurysms lose one or two. Shape: saccular CAAs transverse diameter is greaterthan the longitudinal diameter. They are often seen distal to stenosis and are more prone tothrombosis or rupture. Fusiform aneurysms involve the whole vessel circumference, havegreater longitudinal measurement, and have no relationship to stenosis. Size: small (diameter<5 mm), medium (5-8 mm), and giant (>8 mm) [3].Incidence varies from 0.3% to 5.3% (mean of 1.65%). Men have more CAAs than women: 2.2%vs. 0.5%. Most frequent locations are right coronary (40%-70%), LCX (23.4%), and LAD (32.3%)arteries. Left main coronary artery is affected significantly less (0.1%-3.5%) (Figure 5) [4,5].Prevalence of giant CAA in a general population is only 0.02% [1]. FIGURE 5: Distribution and fréquence of coronary arteryaneurysms2020 Malyshev et al. Cureus 12(4): e7653. DOI 10.7759/cureus.7653 5 of 7LM, left main coronary artery; LAD, left anterior descending artery; LCX, left circumflex artery; RCA,right coronary arteryThe etiology of CAA varies depending on age and geographical area. Atherosclerosis isresponsible for half of CAAs in the West, followed by congenital (17%) and infectious (10%)aneurysms. Kawasaki disease is the dominant cause of CAA in Japan [3]. Inflammatorydisorders and connective tissue diseases are usually associated with ectasias and are morefrequent in younger patients [3]. Iatrogenic causes include trauma from balloon inflationpressure, intervention in acute myocardial infarction, use of nonsteroidal anti-inflammatorydrugs, steroids, and colchicine, which can cause improper healing. Cocaine causes severehypertension and vasoconstriction, thus damaging the endothelium and promoting CAAformation [6].CAAs in CAD are thought to be caused by turbulent blood flow damaging the wall [3]. However,there must be other factors because most patients with CAD do not develop CAA.Usually patients are asymptomatic and most CAAs are found incidentally. Presentation dependson the etiology and/or complications. Complications of CAA include embolization, rupture,fistula formation, tamponade, hemopericardium, dissection, vasospasm, and vesselcompression [2,3].Coronary angiography remains the best method to identify CAA [2]. It provides informationabout location, size, and shape of CAA, but it only sees the vessel lumen. Thus, the true size ofCAA could be underestimated, or CAA can be missed if thrombus occludes it [4]. Intravascularultrasound corrects these limitations, providing transmural images and information about wallstructure and luminal composition [4,7]. CT coronary angiography provides fast informationabout CAA’s location, shape, size, and wall composition, but no treatment option. CTangiography is useful in following patients with known CAAs [4].Management of CAA depends on presentation, etiology, size, location, associated infection,and extent of atherosclerosis [4]. In adults with CAD, medical reduction of cardiovascular riskfactors should be started. Long-term antiplatelets and potentially anticoagulation should bestarted since thrombosis and/or embolism are of concern [8]. Percutaneous intervention withstent placement can be done in aneurysm with diameter up to 10 mm [9]. Surgery is indicatedin patients, who are not candidates for percutaneous intervention, obstructive CAD, and largesaccular aneurysms at risk for rupture [4,10].ConclusionsThe first case of CAA was published in 1812. It was found post-mortem after sudden death.Since then our understanding of the pathology, etiology, and progression of CAAs hasimproved. Today we can find these potentially deadly aneurysms during routine angiogram, notpost-mortem. However, their management is still challenging and has to be tailored specificallyto each patient. More research is needed to identify patients, who are at risk to diagnose CAAearlier, manage it better, and prevent complications. Additional InformationDisclosuresHuman subjects: Consent was obtained by all participants in this study. Conflicts of interest:In compliance with the ICMJE uniform disclosure form, all authors declare the following:2020 Malyshev et al. Cureus 12(4): e7653. DOI 10.7759/cureus.7653 6 of 7Payment/services info: All authors have declared that no financial support was received fromany organization for the submitted work. Financial relationships: All authors have declaredthat they have no financial relationships at present or within the previous three years with anyorganizations that might have an interest in the submitted work. Other relationships: Allauthors have declared that there are no other relationships or activities that could appear tohave influenced the submitted work.References1. Li D, Wu Q, Sun L, et al.: Surgical treatment of giant coronary artery aneurysm. J ThoracCardiovasc Surg. 2005, 130:817-821. 10.1016/j.jtcvs.2005.04.0042. Pahlavan PS, Niroomand F: Coronary artery aneurysm: a review . Clin Cardiol. 2006, 29:439-443. https://doi.org/10.1002/clc.49602910053. Diaz-Zamudio M, Bacilio-Perez U, Herrera-Zarza MC, et al.: Coronary artery aneurysms andectasia: role of coronary CT angiography. Radiographics. 2009, 29:1939-1954.10.1148/rg.2970950484. Abou Sherif S, Ozden Tok O, Taskoylu O, Goktekin O, Kilic ID: Coronary artery aneurysms: areview of the epidemiology, pathophysiology, diagnosis, and treatment. Front CardiovascMed. 2017, 4:24. 10.3389/fcvm.2017.000245. Swaye PS, Fisher LD, Litwin P, et al.: Aneurysmal coronary artery disease . Circulation. 1983,67:134-138. 10.1161/01.cir.67.1.1346. Satran A, Bart BA, Henry CR, et al.: Increased prevalence of coronary artery aneurysms amongcocaine users. Circulation. 2005, 111:2424-2429. 10.1161/01.CIR.0000165121.50527.DE7. Porto I, MacDonald S, Banning AP: Intravascular ultrasound as a significant tool for diagnosisand management of coronary aneurysms. Cardiovasc Intervent Radiol. 2004, 27:666-668.10.1007/s00270-004-0038-08. Nichols L, Lagana S, Parwani A: Coronary artery aneurysm: a review and hypothesis regardingetiology. Arch Pathol Lab Med. 2008, 132:823-828. https://doi.org/10.1043/1543-2165(2008)132[823:CAAARA]2.0.CO;29. Szalat A, Durst R, Cohen A, Lotan C: Use of polytetrafluoroethylene-covered stent fortreatment of coronary artery aneurysm. Catheter Cardiovasc Interv. 2005, 66:203-208.10.1002/ccd.2044810. LaMotte LC, Mathur VS: Atherosclerotic coronary artery aneurysms: eight-year angiographicfollow-up. Tex Heart Inst J. 2000, 27:72-73.2020 Malyshev et al. Cureus 12(4): e7653. DOI 10.7759/cureus.7653 7 of 7

Giant Left Main Coronary Artery Aneurysm Presenting as Multiple Implantable Cardioverter Defibrillator Shocks

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Giant Left Main Coronary Artery Aneurysm Presenting as Multiple Implantable Cardioverter Defibrillator Shocks

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