Suspected contained rupture of a coronary artery aneurysm followed by a re-rupture: a case report

Abstract

Background: Most coronary artery aneurysms (CAAs) are clinically asymptomatic and are only detected incidentally during cardiac imaging. However, CAAs can cause fatal complications such as cardiac tamponade following a rupture. Reports of contained ruptures of CAAs are limited.

Case summary: An 89-year-old man had a severe, acute-onset chest pain 2 days prior. The patient was referred to our hospital because of residual dyspnoea and a fever. The blood tests exhibited high C-reactive protein and D-dimer levels; moreover, contrast-enhanced computed tomography (CT) and transthoracic echocardiography revealed a diffuse mild pericardial effusion, which had not been detected six months prior. The fever and pericardial effusion persisted, and the main cause was not clearly understood. On Day 19, the patient had a sudden loss of consciousness after chest pain. Contrast-enhanced CT showed an increase in the pericardial effusion, and coronary angiography showed a CAA in the proximal right coronary artery with extravasations that probably sealed. A re-rupture following a contained rupture of the CAA was considered, and it was suspected that the prolonged fever and pericardial effusion were related to the contained rupture associated with the first episode of chest pain.

Discussion: Our case showed that a contained rupture of a CAA can cause a fatal event by a re-rupture and may present with a prolonged fever and pericardial effusion. A contained rupture of a CAA should be considered as a differential diagnosis in patients with a prolonged fever and pericardial effusion of unknown origin after an acute onset of chest pain.

Keywords: Case report; Contained rupture; Coronary artery aneurysm; Fever of unknown origin; Pericardial effusion.

Figure 1

Although chest radiography six months prior did not show any enlargement of the cardiac silhouette [cardio-thoracic ratio (CTR) of 47%] (A), that performed on admission revealed a significant enlargement (CTR of 67%) (B). Transthoracic echocardiography six months prior did not show any abnormal findings of a pericardial effusion (C); however, a diffuse mild pericardial effusion without a collapse of the right heart was observed on admission (arrows) (D). Non-electrocardiogram-gated contrast-enhanced computed tomography (CT) with a 320-row detector revealed a diffuse mild pericardial effusion, slight bilateral pleural effusion, and severe calcifications of the coronary arteries (E–G). The mean CT value near the right heart was 26.5 Hounsfield unit (HU), which was slightly higher than that near the left heart, 18.8 HU (circle) (E and F).

Figure 2

Time course of the fever and C-reactive protein and D-dimer levels in addition to the medications during the hospitalization. CRP, C-reactive protein.

Figure 3

Just after the second episode of chest pain and loss of consciousness, the electrocardiogram (ECG) exhibited ST-elevation in the inferior leads (A), but the change recovered within 15 min (B). Non-ECG-gated contrast-enhanced computed tomography (CT) showed an increase in the pericardial effusion, especially on the surface of the right atrium and ventricle (C–E), and the mean CT value near the right heart was 55.5 Hounsfield unit (HU), which was significantly higher than that near the left heart, 23.8 HU (circle) (D and E). There was contrast extravasation from the proximal right coronary artery in the axial plane (white arrow) (F) and in the maximum intensity projection (black arrow) (G). Ao, aorta; LV, left ventricle; PA, pulmonary artery; RCA, right coronary artery; RV, right ventricle.

Figure 4

Emergency coronary angiography showed an irregular margin of the coronary artery aneurysm (CAA) in the proximal right coronary artery (RCA) (asterisk), pulsatile contrast extravasations that probably sealed from three sites of the CAA (black arrows) (A and B), and a Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow in the right and left coronary arteries (A–D). Haemostasis by percutaneous coronary intervention using two 3.5/20 mm PK Papyrus covered stents was performed (dot arrow) (E and F). The final angiography showed that the CAA was successfully sealed by the covered stents, and there was a TIMI grade 3 flow in the RCA (G). CAU, caudal; CRA, cranial; LAO, left anterior oblique; RAO, right anterior oblique.