2 ︱ CASE PRESENTATION
A 50-year-old female presented to a community clinic due to fatigue
after activities and was primarily diagnosed with giant left coronary
artery aneurysm. On admission, she had not received surgery or special
medication previously. Physical examination and electrocardiogram
revealed left-inferior enlargement of the cardiac border, left
ventricular high voltage, and a grade 3/6 systolic murmur could be heard
in the auscultatory mitral area. Chest X-ray showed left
atrioventricular enlargement and right coronary calcification.
Transthoracic echocardiography (TTE) indicated a 7.1×7.4 cm cyst-like
aneurysm at the upper back of the left atrium, which originating from
the left coronary artery, detouring to the left posteriorly, and
breaking into the right atrial appendage; accompanied by moderate mitral
and tricuspid regurgitation (FIGURE 1). Concurrently, the
left coronary artery ostium
dilated up to 2.8 cm, and the possibility of RASA should be further
precluded. Then cardiac three-dimensional computed tomography (3D-CT)
was recommended to reconstruct the aneurysm. Cardiac 3D-CT revealed a
RASA of the left coronal sinus and an aneurysm-like fistula connecting
the left main coronary artery with the right atrium, squeezing the right
pulmonary vein and left atrium (FIGURE 2). During operation,
transesophageal echocardiogram
(TEE) and surgical vision confirmed these findings (FIGURE 3, VIDEO
1-3). Under cardiopulmonary bypass, the patient underwent RASA repair,
coronary artery bypass grafting (great saphenous vein graft to left
anterior descending and circumflex branches), mitral and tricuspid
valvuloplasty, and temporary pacemaker implantation. Following
operation, TEE confirmed that there was no flow in the right atrial
fistula, and the aneurysm in the posterior wall of the left atrial was
collapsed. The patient was fully recovered and discharged home at 14th
day after operation.