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Saccular ascending aorta aneurysm: report of an unusual presentation

Cardiac Surgery Department, University of Parma, Parma, Italy

Received 29 November 2007; received in revised form 27 January 2008; accepted 28 January 2008

*Corresponding author. Sezione di Cardiochirurgia, Università degli Studi, Via A. Gramsci 14, 43100 Parma, Italy. Tel.: +39 (0) 521 703270; fax +39 (0) 521 293196.

E-mail address: francesco.nicolini{at}unipr.it (F. Nicolini).

	Abstract

Top Abstract 1. Introduction 2. Clinical summary 3. Discussion Acknowledgements References

 
We describe an unusual presentation of a large saccular aneurysm of the ascending aorta, mimicking an acute coronary syndrome. The compression of the aneurysm on the left main coronary artery was probably the cause of these confusing symptoms. Our experience confirms the fundamental role of modern cardiac imaging techniques in the differential diagnosis of these unusual cases and in the planning of the correct surgical procedure.

Key Words: Aortic aneurysm; Cardiac surgery

	1. Introduction

Top Abstract 1. Introduction 2. Clinical summary 3. Discussion Acknowledgements References

 
We describe the unusual clinical presentation of a saccular ascending aorta aneurysm in a 70-year-old female patient.

	2. Clinical summary

Top Abstract 1. Introduction 2. Clinical summary 3. Discussion Acknowledgements References

 
The patient had no clinical history of symptoms or signs of ischemic coronary artery disease and was admitted to our institution for sudden chest pain associated with systemic severe hypotension and ST segment elevation in postero-inferior ECG leads. Serum levels of specific myocardial necrosis markers were not significant.

Trans-thoracic echocardiography showed good function of the left ventricle with moderate pericardial effusion not causing tamponade, and generally excluded signs of aortic root disease. Blood pressure was stabilized with intravenous plasma expanders and low dosage dopamine administration. Emergency coronary artery angiography excluded coronary artery obstructive disease, and revealed a large saccular ascending aorta aneurysm (mean diameter 5x5 cm) rising from the posterior ascending aortic wall, just above the sino-tubular junction (Figs. 1a, 2a). As a consequence of the hemodynamic stability and the absence of signs of impending rupture, before surgery the patient underwent a CT-scan which confirmed the diagnosis (Figs. 1b,c, 2b).

View larger version (48K): [in this window] [in a new window]   Fig. 1. (a) Angiography showing saccular ascending aorta aneurysm (white arrow). (b,c) 3-dimensional reconstruction CT-scan and contrast CT-scan showing saccular aneurysm (asterisk) and the origin of left main stem (red arrow).

View larger version (55K): [in this window] [in a new window]   Fig. 2. (a,b) CT-scan showing displacement of pulmonary artery trunk by the saccular aneurysm (asterisks).

The postoperative period was uneventful and the patient was discharged and referred to a rehabilitation program seven days after the operation. At three months follow-up, the patient is alive and asymptomatic.

	3. Discussion

Top Abstract 1. Introduction 2. Clinical summary 3. Discussion Acknowledgements References

 
We describe an unusual presentation of a large saccular aneurysm of the ascending aorta, mimicking an acute coronary syndrome. The confusing clinical presentation could be explained by the contiguity of the aneurysm with the origin of the left main stem, causing initial electrocardiographic modifications. The compression of the aneurysm on the left main coronary artery could also be responsible for the unusual onset of symptoms mimicking an evolving acute myocardial infarction, such as sudden chest pain associated with systemic severe hypotension.

Between 25% and 33% of patients affected by ascending aorta aneurysm report chest pain but associated electrocardiographic ischemic abnormalities have been occasionally described only in the case of sinus of Valsalva aneurysms [1].

In our case, the clinical stability, the absence of signs of impending rupture, the convenience and speed of performing a thoracic CT-scan at the radiology laboratory of our Hospital, situated next to heart surgery operating theatres, prompted us to submit the patient to thoracic tomography before surgery. In fact, a CT-scan also allows us to study the aortic wall better than aortography with the aim of specifying anatomic relationships of the aneurysm with other organs.

It is rare to see such incipient and impending rupture of an ascending aortic saccular aneurysm on surgical inspection [2], particularly as, in this case, preoperative angiography and CT-scan showed no signs of impending fissuration. Our experience confirms the fundamental role of performing modern cardiac imaging techniques in the differential diagnosis of these unusual cases and planning the correct surgical procedure.

	Acknowledgements

Top Abstract 1. Introduction 2. Clinical summary 3. Discussion Acknowledgements References

 
We thank Lois Clegg, English language teacher, University of Parma, for her assistance in the revision of the manuscript.

	References

Top Abstract 1. Introduction 2. Clinical summary 3. Discussion Acknowledgements References

 

1. Edmunds LH Jr. Cardiac surgery in the adult. New York: McGraw Hill; 1997:1170.
2. Origuchi N, Ohkawa S, Esaki F, Yoshida Y, Shigematsu H. Rare complication of saccular aneurysm and histological dissection. An autopsy study of 5865 elderly cases. Jpn Heart J 2001;42:597–606.[CrossRef][Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Francesco Nicolini Cesare Beghi Tiziano Gherli Permission Requests Citing Articles Citing Articles via HighWire Google Scholar Articles by Borrello, B. Articles by Gherli, T. PubMed PubMed Citation Articles by Borrello, B. Articles by Gherli, T. Related Collections Related Article