Another cause of cardiac tamponade: ruptured coronary artery aneurysm
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Coronary artery aneurysm can be defined as an abnormal dilatation of the coronaries. In recent years, the disease has been frequently encountered during surgical procedures such as percutaneous coronary intervention (PCI) and coronary computed tomography angiography (CCTA).
We reported a case of cardiac tamponade due to spontaneous rupture of coronary artery aneurysm in a 53-year-old Chinese man, who had collapsed and died at home after returning from work. Autopsy revealed a cardiac tamponade with ruptured aneurysm of the left circumflex artery.
This case highlights the need to consider ruptured coronary aneurysm as a differential diagnosis when cardiac tamponade is encountered during autopsy.
KeywordsCardiac tamponade Coronary artery Aneurysm CCTA Forensic
Coronary artery aneurysm
Coronary artery ectasia
Coronary computed tomography angiogram
Verhoeff-Van Gieson elastic stain
Left circumflex coronary artery
Left main stem
Left main coronary artery
Percutaneous coronary intervention
Coronary artery aneurysm (CAA) is defined as the diameter of the lumen of the coronary artery, generally exceeding 1.5 times the normal adjacent segment, which may involve less than one third of the whole length of the vessel (Tunick et al. 1990; Kruger et al. 1999). Another similar pathology, i.e. coronary artery ectasia (CAE), is also characterised by dilatation of the coronary artery, with a diameter exceeding 1.5 times, or more than the normal adjacent segment. However, the difference between CAA and CAE is that CAE is more diffuse, affecting more than one third of the length of the coronary artery (Aboeata et al. 2012). Based on the size of the aneurysm, it can be considered as a giant coronary aneurysm, if the diameter is more than 20 mm (Jha et al. 2009).
According to a survey conducted by Daoud et al. (1963), the majority of coronary aneurysm (more than 50%) was caused by atherosclerosis, followed by congenital disorders and mycotic and syphilitic diseases (Daoud et al. 1963). The results were similar to that by Luo et al. (2016), where 68.2% of patients with CAA had coronary artery disease (CAD), in comparison to only 39.2% of CAE patients, who had CAD (Luo et al. 2016). Post-coronary intervention and connective tissue disorder were among the conditions reported in the incidence of coronary artery aneurysm (Swaye et al. 1983; Rognoni et al. 2007).
Patients with aneurysm of the coronary artery may be asymptomatic. However, it can cause fatal complications such as myocardial infarction and cardiac tamponade. We, thus, reported a case of sudden death due to ruptured aneurysm of coronary artery in a 53-year-old male, who had no history of connective tissue disorder prior to his death.
A 53-year-old Chinese man was found collapsed and died at home. He had previous history of gouty arthritis. He was brought to the mortuary of the Universiti Kebangsaan Malaysia Medical Center for an autopsy upon request by the police.
Ruptured aneurysm is a rare complication of CAA, besides thrombosis, embolization and ischaemia (Daneshvar et al. 2012). Once CAA is ruptured, it can cause cardiac tamponade and sudden death can occur. The incidence of CAA was reported to occur between 1.5 and 4.9%. The RCA is the commonest coronary artery being affected (Syed and Lesch 1997; Hartnell et al. 1985), with LMCA being the least involved in aneurysm, as none was seen in a survey by Swaye et al. (1983) (n = 1200), and only 22 were seen in another survey (n = 22000) (Topaz et al. 1991).
In this interesting case, the diameter of the dilated LCX was 3 cm, which was 1.5 times bigger than the diameter of the normal adjacent segment (0.5 cm). The total length of the dilatation was 7 cm, where 3.5 cm was located at LMCA, which extended to LCX for another 3.5 cm. The dilatation at LCX had involved one third of the whole length of the artery (10 cm). The aneurysm had involved LMCA, which extended to the proximal part of LCX, and these findings were rare and atypical. This giant aneurysm was almost similar to a previous case, where the aneurysm (7 × 5 × 4 cm) was presented at the right coronary artery (Kondo et al. 2015). The most likely cause of the aneurysm was coronary atherosclerosis with underlying hypertension as the predisposing factor, which led to rupture of the aneurysm.
In conclusion, this case represents a giant coronary artery aneurysm in an atypical location, i.e. left main coronary artery. It is worth mentioning that ruptured coronary artery aneurysm found during autopsy must always trigger a differential diagnosis that includes cardiac tamponade.
We would like to thank all the forensic staffs of Universiti Kebangsaan Malaysia Medical Centre and the police officers who were involved in the investigation of this case.
All authors have made substantial contributions to this article. All authors read and approved the final manuscript.
Ethics approval and consent to participate
This is a case report, and the issues on publication have been informed to the deceased’s wife. The deceased’s wife had consented for the case report publication.
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The wife of the deceased consented for this case report publication with the condition that the deceased’s details remained anonymous.
The authors declare that they have no competing interests.
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- Luo Y, Tang J, Liu X, Qiu J, Ye Z, Lai Y, Yao Y, Li J, Wang X, Liu X (2016) Coronary artery aneurysm differs from coronary artery ectasia: angiographic characteristics and cardiovascular risk factor analysis in patients referred for coronary angiography. Angiology 68(9):823–830CrossRefGoogle Scholar
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