Apr 6, 2006 - 3Department of Surgery, King Abdul-Aziz Medical City, Dammam, Kingdom of ... 4Department of Cardiac Services, King Fahad Armed Forces ...
CardioVascular and Interventional Radiology
ª Springer Science+Business Media, Inc. 2006 Published Online: 6 April 2006
Cardiovasc Intervent Radiol (2006) 29:911–914 DOI: 10.1007/s00270-005-0178-x
An Unusual Aneurysm of the Main Pulmonary Artery Presenting as Acute Coronary Syndrome Mona A. Kholeif,1 Mohamed El Tahir,2 Yasser A. Kholeif,3 Ahmed El Watidy4 1
Department of Medicine, King Khalid National Guard Hospital, King Abdul-Aziz Medical City, P.O. Box 9515, Jeddah 21423, Kingdom of Saudi Arabia 2 Department of Radiology, King Khalid National Guard Hospital, King Abdul-Aziz Medical City, P.O. Box 9515, Jeddah 21423, Kingdom of Saudi Arabia 3 Department of Surgery, King Abdul-Aziz Medical City, Dammam, Kingdom of Saudi Arabia 4 Department of Cardiac Services, King Fahad Armed Forces Hospital, Jeddah, Kingdom of Saudi Arabia
Abstract
Case Report
A 70-year old man presented with retrosternal chest pain. His electrocardiogram showed nonspecific T wave changes. Cardiacspecific troponin I (cTnI) was elevated. His condition was managed as acute coronary syndrome, following which he had two minor episodes of hemoptysis. A CT pulmonary angiogram showed no evidence of pulmonary embolism, but a large mass lesion was seen in the mediastinum. Echocardiography and cardiac MRI demonstrated a large solid mass, arising from the right ventricular outflow tract and causing compression of the main pulmonary artery (MPA). The differential diagnosis included pericardial and myocardial tumors and clotted aneurysm of the MPA. At surgery, a clotted aneurysmal sac was identified originating from the MPA and the defect was healed. Aneurysms of the MPA are rare. They most commonly present with dyspnea and chest pain. Compression of surrounding structures produces protean manifestations. A high index of suspicion coupled with imaging modalities establishes the diagnosis. Blunt trauma to the chest, at the time of an accident 4 years previously, may explain this aneurysm. The patientÕs presentation with chest pain was probably due to compression and/or stretching of surrounding structures. Coronary artery compression simulating acute coronary syndrome has been documented in the literature. The rise in cTnI may have been due to right ventricular strain, as a result of right ventricular outflow obstruction by the aneurysm. This has not been reported previously in the literature. The saccular morphology and narrow neck of the aneurysm predisposed to stagnation leading to clotting of the lumen and healing of the tear, which caused the diagnostic difficulty.
This 70-year old man presented to the emergency room complaining of retrosternal chest pain for 3 days, which had worsened significantly over the preceding hours. The pain was very suggestive, but not typical, of myocardial ischemia. The worsening pain was associated with dyspnea and diaphoresis. He had no previous history of coronary heart disease (CHD). His CHD risk factors were his age and gender, and longstanding diabetes mellitus, for which he was on oral hypoglycemic agents. He was a life-long nonsmoker. There was no past medical history of note apart from a minor road traffic accident (RTA) 4 years previously with trivial blunt trauma to the right lower chest. There were no rib fractures and he did not require hospital admission at the time. His clinical examination was unremarkable apart from an ejection systolic murmur over the base of the heart. There was no evidence of deep venous thrombosis, vasculitis or aortic dissection. His electrocardiogram (ECG) showed nonspecific T wave changes in the inferior and anterolateral leads and a borderline S1Q3T3 pattern. His portable anteroposterior chest radiograph showed mild cardiomegaly and unfolding of the aorta. There was no other abnormality. His cardiac enzymes showed elevated cardiac specific troponin I (cTnI), with a peak of 4.41 ng/ml at 4 hr after presentation (reference level
