Saccular aneurysm of the left main trunk

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A 72-year-old man with a previous history of hypertension and smoking, underwent a cardiological evaluation as part of the work-up for elective abdominal surgery. On admission he did not complain of angina, palpitations or dyspnea. His blood pressure was 120/70 mmHg and pulse rate 80 bpm with sinus rhythm. The chest radiograph and ECG showed no significant abnormalities. Major laboratory findings were within normal limits, including cardiac enzymes, except for moderate hypercholesterolemia. A transthoracic two-dimensional echocardiogram showed a slightly dilated left ventricular cavity (end-diastolic volume of 180 ml), moderately depressed left ventricular function with inferoposterior hypokinesia and an ejection fraction of 42%. Myocardial perfusion scintigraphy both at rest an under dipyridamole stimulation showed evidence of diffuse left ventricular ischemia. A coronary angiogram disclosed a saccular aneurysm, 8 × 7 mm, at the left main trunk bifurcation (Fig. 1a) with wall irregularities of the anterior descending and left circumflex coronary arteries but without hemodynamically significant coronary stenoses. An angio-computed tomography (Fig. 1b) showed mild calcific spots of the left main trunk confirming the presence of the aneurysm but without evidence of thrombotic deposits. The patient was treated conservatively and discharged on a regimen of warfarin, aspirin, β-blockers and statins.
Aneurysms of the left main coronary artery are substantially rare, being found in approximately 0.1% of patients undergoing coronary angiography.1 They are usually atherosclerotic in origin and most of them are clinically silent; however, they may be complicated by myocardial ischemia or infarction, even in the absence of peripheral obstructive coronary artery disease, mainly caused by embolization of atheromatous debris or thrombi from within the aneurysm.2 Due to the rarity of the disease, there is not a consensus on the optimal treatment of left main aneurysms. Giant aneurysms represent an indication for surgical repair usually because of the potential for peripheral embolization, ischemic complications due to compression or even rupture. Surgical treatment may consist in patch repair, resection, exclusion and/or coronary artery bypass grafting.3–7 Smaller aneurysms without associated coronary artery disease may be treated conservatively provided adequate medical treatment with oral anticoagulants and antiplatelet drugs is carried out.8 In our patient a left main aneurysm was an occasional finding at coronary angiography. Its location at the left main bifurcation prevented insertion of an intracoronary stent, while absence of concomitant significant coronary disease and relatively small size excluded a surgical indication, favouring medical treatment with warfarin and aspirin.

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