Post-Traumatic Pseudoaneurysm of the Left Sinus of Valsalva Revealed by an Acute Coronary Compression: An Echocardiographic Case Report

A 69-year-old woman presented with chest pain and electrocardiographic evidence of subacute anterior ischaemia. Transthoracic and transesophageal echocardiography allowed correct diagnosis of a posttraumatic pseudoaneurysm of the left sinus of Valsalva. The large pseudoaneurysm caused compression of the left main coronary artery and was successfully treated by aortic root replacement, left main coronary artery ligation, and arterial bypass.     

Detection of left coronary artery stenosis by transoesophageal echocardiography

The ability of transoesophageal echocardiography to visualizethe left coronary artery was retrospectively analysed in 60consecutive patients without clinical evidence of coronary arterydisease. The left main coronary artery was visualized in 56patients, the proximal circumflex in 34 patients and the proximalanterior descending artery in nine patients. Patency of thesearteries was established in all these patients. Subsequently,a prospective study was undertaken in 23 patients with angiographicallyproven left coronary artery disease. Both the left main coronaryartery and the circumflex artery were adequately visualizedwith transoesophageal echocardiography in all 23 patients, whereasthe anterior descending artery was identified inthree patients.The extent of stenosis in the left main coronary artery andthe circumflex arterywas correctly diagnosed in 18 patients.In five patients the degree of stenosis was overestimated. Thesefindings indicate the potential of transoesophageal echocardiographyto detect or exclude stenosis of both the left main coronaryartery and circumflex artery.     

Transesophageal two- and three-dimensional echocardiographic diagnosis of combined left ventricular pseudoaneurysm and ventricular septal rupture

Two- (2-D) and three-dimensional (3-D) transesophageal echocardiography (TEE) were useful in making the diagnosis of combined left ventricular pseudoaneurysm and ventricular septal rupture in an elderly patient presenting with mediastinitis and worsening heart failure following coronary artery bypass graft surgery. The diagnosis was not suspected clinically. Three-dimensional TEE served to increase the confidence level with which the diagnosis of this combined lesion was made. Additionally, 3-D TEE proved superior to 2-D TEE in assessing the size of the left ventricular rupture site.     

Unruptured left ventricular pseudoaneurysm following myocardial infarction

A 73 year old man developed a left ventricular pseudoaneurysm following acute myocardial infarction. Coronary angiography showed triple vessel disease with total occlusion of the right coronary artery. On left ventriculography, a serpentine-like pseudoaneurysm was demonstrated that originated from the posterobasal wall of the left ventricle and extended to the right ventricular free wall. He underwent coronary artery bypass surgery with no plication of the pseudoaneurysm. An organised thrombus was also found within the cavity of the pseudoaneurysm. He was doing well approximately eight months after the operation. The prognosis might be determined by the organised thrombus, the serpentine-like structure of pseudoaneurysm, the coronary revascularisation, and the vigorous medical management.

Keywords: acute myocardial infarction;  pseudoaneurysm;  coronary artery bypass surgery     

Missed diagnosis of unruptured,huge left ventricular pseudoaneurysm

We report a case of a huge left ventricular pseudoaneurysm following myocardial infarction. Early after myocardial infarction, the pseudoaneurysm was missed during the cardiac examination. The patient underwent coronary bypass surgery with endoaneurysmorraphy of the pseudoaneurysm, and made a satisfactory recovery.     

Assessment of congenital coronary artery fistulas by transesophageal color Doppler echocardiography

PURPOSE: Coronary angiography is the gold standard for imaging the coronary tree, but the relation of coronary artery fistulas to other structures, and their origin and course, may not be apparent. We evaluated the ability of multiplane color Doppler transesophageal echocardiography to identify coronary fistulas. PATIENTS AND METHODS: Twenty-one patients with angiographically confirmed coronary artery fistulas were investigated by transesophageal echocardiography in four Italian hospitals between January 1997 and May 2001. RESULTS: Transesophageal echocardiography correctly diagnosed fistulous connection in all 21 patients. This included 6 patients with connections from the left circumflex artery (into the right chambers of the heart in 5 patients, and into the left ventricle in 1 patient), 10 patients with a fistula arising from the left anterior descending artery or left main coronary artery (with drainage into the right ventricle or main pulmonary artery), and 5 patients with a fistula from the right coronary artery (with drainage sites in the lateral aspect of the right ventricle, the low posterior right atrium, or the superior vena cava). In 4 of the 21 patients, angiography did not identify the precise site of a fistula into the coronary sinus or right ventricle. CONCLUSION: Color Doppler transesophageal echocardiography is useful in the diagnosis and in the precise localization of coronary artery fistulas.     

Ruptured saphenous venous graft pseudoaneurysm presenting as a pulsatile chest mass

A 72‐year‐old man with prior history of coronary artery bypass grafting and sternal wire infection presented with non‐ST‐segment elevation myocardial infarction. His coronary angiogram revealed stenosis of the distal left main coronary artery (LMCA) and a pseudoaneurysm of saphenous venous graft (SVG) to right posterior descending artery. Patient developed ventricular fibrillation during admission, and postcardiopulmonary resuscitation, a pulsatile chest mass was observed which was diagnosed with computed tomography as a chest wall collection resulting from rupture of the pseudo‐aneurysm. He underwent percutaneous coronary intervention of the LMCA with drug‐eluting stents followed by successful coil embolization of the SVG pseudoaneurysm. Patient had an uneventful recovery postprocedure.     

Intraoperative echocardiographic assessment of the severe isolated ostial stenosis of left main coronary artery before and after surgical patch angioplasty.

Isolated critical ostial stenosis of left main coronary artery is currently treated by conventional bypass surgery. Surgical patch angioplasty in an alternative surgical approach. Transesophageal echocardiography enables visualization of proximal branches of left and right coronary artery. The report describes intraoperative echocardiographic assessment of surgical left main coronary artery angioplasty.     

Acute large pseudoaneurysm of the left anterior descending artery following bypass surgery: combined percutaneous approach with a PTFE-coated coronary stent and coil embolization

Injury of a native coronary vessel during coronary artery bypass grafting (CABG) is very rare. We report a case of a 76-year-old patient who developed a large pseudoaneurysm of the left anterior descending artery following CABG. The patient was then successfully treated by polytetrafluorethylene (PTFE)-stent graft implantation and percutaneous coil embolization. A coronary artery pseudoaneurysm caused by intraoperative damage has not been described previously.     

Endovascular approach to treat ascending aortic pseudoaneurysm in a patient with previous CABG and very high surgical risk

Pseudoaneurysm of the ascending aorta is an uncommon pathology and a challenge in high‐risk patients who undergo conventional surgery because of high operative morbidity and mortality. Endovascular exclusion of an aortic pseudoaneurysm using an endoprosthesis is a less invasive approach, but few such cases have been reported. Moreover, the use of this approach poses unique therapeutic challenges because there is no specific endoprosthesis for ascending aortic repair, particularly to treat patients with previous coronary artery bypass graft (CABG). We describe the case of a 74‐year‐old patient who had undergone CABG and later presented with an iatrogenic ascending aortic pseudoaneurysm that occurred during an angiography. This patient was at very high risk for surgical treatment and, therefore, an endovascular approach was adopted: percutaneous coronary intervention for the left main coronary artery, left anterior descending and left circumflex native coronary arteries followed by endovascular endoprosthesis deployment in the ascending aorta to exclude the pseudoaneurysm. Both procedures were successfully performed, and the patient was discharged without complications 4 days later. At 5 months' clinical follow‐up, his clinical condition was good and he had no complications. © 2011 Wiley‐Liss, Inc.     

Dynamic Systolic Compression of the Left Anterior Descending Coronary Artery as the First Clue of Postinfarction Left Ventricular Pseudoaneurysm

Left ventricular pseudoaneurysm and left ventricular free wall rupture are rare but life-threatening complications of acute myocardial infarction. Dynamic systolic compression of the coronary arteries is almost always due to myocardial bridging. However, it has rarely been described in patients with ventricular aneurysms and pseudoaneurysms. We present a case of a patient with recent myocardial infarction who presented with recurrence of chest pain and coronary angiogram showing patent vessels however with systolic compression of the distal left anterior descending coronary artery as a first clue to postinfarct left ventricular pseudoaneurysm.     

Incremental benefit of three‐dimensional transesophageal echocardiography in the assessment of left main coronary artery stent protrusion

Ostial lesions represent a challenging clinical scenario and percutaneous intervention (PCI) of left main coronary artery ostial lesions has been associated with postintervention complications, including protrusion of deployed stents into a sinus of Valsalva or aortic root. We report a case of stent protrusion into the aortic root following aorto‐ostial left main coronary artery PCI, in which three‐dimensional transesophageal echocardiography (3DTEE) provided incremental benefit over standard two‐dimensional images. Specifically, 3DTEE confirmed the presence of stent protrusion by allowing clear visualization of the stent scaffold, in addition to characterizing the relationship between the stent and surrounding structures.     

冠状动脉内支架置入术在冠心病治疗中的应用

目的 :评价冠状动脉内支架置入术在冠心病治疗中的临床应用价值。方法 :对 186例 2 0 4支冠状动脉病变内置入 2 2 9只支架 ,其中置入左前降支 12 3只 ,右冠状动脉 73只 ,左回旋支 31只 ,左主干 2只。结果 :186例全部置入成功。置入后经冠状动脉造影证实狭窄消失 ,即刻效果良好。其中 12例急性心肌梗死患者急诊置入支架后 10例病情迅速缓解 ,2例术后死亡 ,死因分别为再次心肌梗死和颅内出血。择期冠状动脉支架置入术无一例死亡。其他并发症为股动脉假性动脉瘤 2例 ,术后低血压反应 9例。结论 :冠状动脉内支架置入术是治疗冠心病的一种安全可靠、效果良好的介入性治疗方法 ,值得临床广泛应用。     

Ultrafast computed tomography in management of post-bentall aortic root pseudoaneurysm repair

A giant pseudoaneurysm adjacent to the sternum was diagnosed in a patient who had undergone aortic root replacement with use of the Bentall operation 10 years earlier. Electron-beam computed tomography showed that the right coronary artery, which could not be seen on angiography, originated from the pseudoaneurysm itself. At reoperation, we found that both coronary ostia were detached and that the right coronary ostium was totally detached. The source of the right coronary artery blood flow was the pseudoaneurysm itself The defect at the left coronary artery attachment site was repaired primarily. A vein graft was interposed between the ostium of the right coronary artery and the native aorta, distal to the graft anastomosis.     

A Suprasternal Approach to Assess the Proximal Coronary Arteries in Infants and Children

The authors propose a two-dimensional echocardiographic approach to demonstrate the origin and proximal course of the coronary arteries in children, which could be called “suprasternal right anterior oblique cut”. The important feature disclosed by this new view, but not by the classic parasternal short-axis cut, is the spatial relationship between the origin of the coronary arteries, the aortic root, and the ascending aorta. The knowledge of this anatomical feature may be of surgical significance in the setting of congenital heart diseases, such as tetralogy and transposition or acquired coronary diseases, such as Kawasaki's syndrome. The suprasternal right anterior oblique cut was obtained by rotating the transducer counterclockwise, with slight anterior tilting, from the classic long-axis view of the aorta, for imaging the left coronary artery. The left coronary artery arises as a main trunk from the upper portion of the left coronary sinus, passes behind the pulmonary trunk and beneath the left atrial appendage for a few millimeters up to the point of bifurcation. Because of the orientation of the ultrasound beam, the left coronary is shown between the right pulmonary artery and the left atrial appendage in this cut. To assess the right coronary artery, the transducer was slightly deviated to the right and further rotated counterclockwise, while very carefully tilted anteriorly. Fifty consecutive children (29 males, 21 females), with a mean age of 5.4 ± 4.1 years, were evaluated from May to July 1992, in order to demonstrate the feasibility of the proposed approach. The left coronary artery was disclosed in 100% of cases, and the right in 76%. The 12 patients in which the right coronary artery was not visualized were significantly older than the group in which both coronary arteries were demonstrated (P < 0.001). It was concluded that the suprasternal right anterior oblique two-dimensional echocardiographic cut for demonstration of the coronary arteries in children is easy to perform, reproducible, and allows the assessment of anatomical features not disclosed by the classic approach.     

Mitral‐aortic intervalvular fibrosa pseudoaneurysm causing compression of superior vena cava and right atrium

The mitral‐aortic intervalvular fibrosa (MAIVF) is a fibrous, avascular region between the anterior leaflet of the mitral valve and noncoronary cusp of the aortic valve. This makes MAIVF vulnerable to injury and infection; thus pseudoaneurysm may develop. The pseudoaneurysm can cause compression to coronary arteries which causes angina or pulmonary artery resulting in pulmonary hypertension. We presented the pseudoaneurysm of MAIVF causing compression of superior vena cava and right atrium which was visualized by two‐ and three‐dimensional transesophageal echocardiography and cardiac computed tomography.     

Atypical Bland-White-Garland syndrome: a 58-year-old woman with stenosis of the pulmonary origin of the left coronary artery

The anomalous origin of the left coronary artery from the main pulmonary trunk (also known as Bland-White-Garland syndrome) is a rare congenital malformation that occurs in 0.4% of patients with cardiac anomalies. We present an adult case (a 58-year-old woman) of atypical Bland-White-Garland syndrome. The patient displayed a stenosis at the ostium of the anomalous origin of the left coronary artery and an aortopulmonary fistula. Using conventional angiography, it was not possible to differentiate between an anomalous origin of the pulmonary coronary artery and total stenosis of the left main coronary artery in combination with a pulmonary fistula. However, transesophageal echocardiography (TEE) succeeded in making this differential diagnosis. CONCLUSION: If there is subtotal or total occlusion, TEE can be used for detection of coronary vessel morphology, particularly in cases of coronary anomalies.     

Left ventricular pseudoaneurysm caused by coronary spasm,myocardial infarction,and myocardial rupture

We report a very rare case of a 47-year-old man who had coronary spasm that resulted in a silent myocardial infarction, a ruptured myocardial wall, and a nonruptured left ventricular pseudoaneurysm. The patient presented with a 6-month history of dyspnea on exertion, without evidence of fixed coronary artery stenosis. Coronary angiography showed severe coronary spasm of the left anterior descending and left circumflex arteries; the spasm was relieved promptly by nitroglycerin. Echocardiography and left ventricular angiography revealed the large left ventricular pseudoaneurysm posterolateral to the left ventricle. We performed surgical resection of the pseudoaneurysm and patch repair of the ruptured left ventricular wall, with excellent results. We present this case because of the highly unusual sequence of events. Early surgical intervention resulted in the patient's recovery.     

Left ventricular pseudoaneurysm after coronary artery bypass and valve replacement for post-infarction mitral regurgitation

Most left ventricular inferior wall aneurysms are classified as false, and they have a narrow neck and exhibit rapid flow. Inferior wall pseudoaneurysms that develop soon after primary percutaneous intervention and coronary artery bypass grafting for acute myocardial infarction are rare. We report the case of a 64-year-old man who had a wide-necked left ventricular inferior wall pseudoaneurysm that developed soon after surgery for an acute myocardial infarction and post-infarction mitral regurgitation that occurred as a mechanical complication. The surgery consisted of coronary artery bypass grafting and mitral valve replacement. After the surgery, congestive heart failure developed. At reoperation, we found a large pseudoaneurysm that had caused tearing of the chordae tendineae of the posterior mitral leaflet and scarring around the inferior wall defect. The inferior wall defect had formed the wide neck of the left ventricular pseudoaneurysm. We excised the pseudoaneurysm and the scar tissue and attached a small patch to the defect such that it decreased the left ventricular dimension. Our patient survived the surgery and recovered completely. In patients with acute myocardial infarction, left ventricular pseudoaneurysms can occur soon after coronary artery bypass grafting and surgery for a complication such as mitral valve regurgitation. When a large portion of the left ventricular wall is infarcted and its removal would create a smaller cavity with compromised output, we recommend ventricular reconstruction by patch placement.     

Percutaneous device closure of a pseudoaneurysm of the left ventricular wall

The percutaneous device closure of a left ventricular pseudoaneurysm is described in a 60 year old man with a history of myocardial infarction complicated by ventricular tachycardia and left ventricular aneurysm treated by coronary artery bypass grafting and aneursymectomy with ventricular tachycardia ablation. He subsequently developed a vast pseudoaneurysm of the left ventricle with New York Heart Association functional class II heart failure symptoms. The selection of the approach and type of device used to close the neck of the pseudoaneurysm are discussed.