Position dependent right ventricular dysfunction caused by a giant right coronary artery aneurysm

Abstract

We describe an instructive case of a 79-year-old patient with a giant coronary aneurysm and a second smaller aneurysm with an uncommon symptomatology. Giant coronary artery aneurysms (>2 cm diameter) are rare pathologic entities with a prevalence of 0.02%. They either can be congenital malformations or are atherosclerotic in origin. Although spontaneous rupture of giant coronary artery aneurysms has been reported, they generally remain silent or induce myocardial ischemia. Our patient, however, showed no signs of myocardial malperfusion but transient position-dependent pre-syncope. The cardiologic work-up and the intraoperative considerations regarding patient management are described. During surgery, manipulation of the giant coronary artery aneurysm caused impairment of right ventricular function and regional wall hypokinesia, as assessed by transesophageal echocardiography. Venous cannulation of the right atrium was thus abandoned and extracorporeal circulation was established via the femoral vein. Subsequent dissection and surgical repair were uneventful and further recovery of the elderly patient was uncomplicated. This case underlines that once the diagnosis is established, proper perioperative management enables successful surgical treatment even of patients of advanced age.