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Left Main Coronary Artery Aneurysm Presenting as Ischemic Heart Disease

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Left Main Coronary Artery Aneurysm Presenting as Ischemic Heart Disease
Anna Olds, Siavash Saadat, Antonio Chiricolo, Ashish Awasthi, Leonard Y. Lee. 
Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.

PATIENT DEMOGRAPHICS: Seventy three year old Caucasian female, nonsmoker.
RELEVANT HISTORY: A 73-year old female with a history of diabetes, hypertension, MSSA positive septic knee treated with antibiotics, and a pericardial effusion presented with dyspnea and chest pain, concerning for non-ST elevation acute coronary syndrome. Chest X-rays demonstrated bilateral pleural effusions, an echocardiogram demonstrated decreased left ventricular systolic function with ejection fraction of 25%, and elevated troponin-I of 1ng/mL. After developing cardiogenic shock with pulmonary edema and hypotension, the patient was intubated. Cardiac catheterization revealed 99% stenosis of the left mainstem coronary artery (LMCA) and a post-stenotic LMCA aneurysm with thrombus. Subsequent echocardiogram also demonstrated the LMCA aneurysm and new, severe mitral regurgitation.
PRE-OPERATIVE PLAN: Preoperatively, pressors were maintained and an intra-aortic balloon pump was placed to maintain hemodynamic status with progressive cardiogenic shock and severe acute mitral regurgitation. The plan was to proceed with urgent coronary artery bypass grafting (CABG) and mitral valve repair (MVR).
DISCUSSION: The patient underwent ligation of the left coronary ostium and exclusion of the LMCA aneurysm with CABGx2 via standard sternotomy. The patient also underwent MVR and pericardial stripping. The parietal pericardium was thickened, leathery, and densely adherent to the visceral pericardium. Pathological examination of the pericardium confirmed acute fibrinous pericarditis with granulation tissue. Access to the left atrium revealed a Type 1 mitral valve with annular dilatation causing mitral regurgitation, which was repaired with a 28mm annuloplasty ring. Inspection of the LMCA after standard transverse aortotomy revealed an aneurysm extending from the ostium with thrombus. The LMCA aneurysm was over-sewn with 4-0 pledgeted Prolene in a mattress fashion to exclude it from circulation and the thrombus was left in situ. We presumed that there would be minimal retrograde flow due to the 99% occlusion of the LMCA, which would likely thrombose. A reverse saphenous vein graft was placed to the obtuse marginal artery, and the left internal mammary artery was used to bypass the left anterior descending artery. The patient underwent uncomplicated recovery in the ICU and was discharged on postoperative day 6 to rehabilitation.

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