Natural History, Clinical Consequences, and Morphologic Features of Coronary Arterial Aneurysms in Adults




Clinical and morphologic features are described in 20 adults (15 men) aged 17 to 85 years (mean 56) who at necropsy were found to have ≥1 aneurysm in ≥1 of their 3 major (right, left anterior descending, and left circumflex) epicardial coronary arteries. Of the 34 coronary aneurysms in the 20 patients (single in 10 patients, ≥2 in 10 patients), 27 (79%) contained intra-aneurysmal thrombi, and in each, the thrombus severely narrowed the lumen. Additionally, atherosclerotic plaque was present in the aneurysmal wall in all 27 aneurysms containing thrombi and also in the major coronary arteries uninvolved by aneurysm. The causes of the aneurysms in the 16 patients with intra-aneurysmal thrombi were therefore considered atherosclerotic. In the other 4 patients, with 7 aneurysms, none contained intra-aneurysmal thrombus or atherosclerotic plaque, and the aneurysms were considered congenital. Clinical diagnosis of coronary aneurysm was not made in any of the 20 patients, but none had proper imaging studies during life. Despite the coronary aneurysms and the associated luminal narrowing, only 8 patients (40%) had left ventricular wall scarring or necrosis or clinical evidence of myocardial ischemia. Proper therapy remains ill defined.


Although atherosclerosis commonly involves the aorta, a common consequence of that involvement is aneurysmal dilatation, most commonly involving the abdominal portion, and significant narrowing or total occlusion of the aorta by this process is rare. In contrast, when atherosclerosis involves the coronary arteries, a common consequence is severe narrowing or total obstruction leading to myocardial ischemia and/or infarction, and aneurysmal dilatation involving these arteries is rare. Indeed, examination of several cardiac pathology books disclosed either no or minimal mention of coronary arterial aneurysm. This report describes clinical and morphologic features in 20 adults with coronary arterial aneurysm observed personally during a 24-year period.


Methods


All hearts were initially examined by the author (W.C.R.), and most were reexamined all together at a later time. The hearts were submitted to W.C.R.’s cardiac pathology laboratory from 12 different medical institutions: 6 from 1 institution, 3 from another, 2 from another, and 1 each from 9 different institutions. The 20 cases were seen by W.C.R. during a 24-year period (1975 to 1999). The hearts were received after fixation in formaldehyde. After excising extraneous tissues, the hearts were weighted, described, and either photographed or illustrations prepared.


To be included in this study, ≥1 of the major epicardial coronary arteries (left anterior descending, left circumflex, and right) had to be focally dilated. The diameter of the aneurysm had to be ≥2 times the diameter of the right and left main coronary arteries in the first centimeter of their courses. Patients with previous cardiac surgery or percutaneous coronary intervention were excluded. Clinical records were obtained from the submitting institutions.




Results


Pertinent clinical and morphologic data for each of the 20 patients are listed in Table 1 , and several hearts are illustrated in Figures 1 to 11 .



Table 1

Clinical and morphologic cardiac data in 20 necropsy patients with ≥1 aneurysm in ≥1 epicardial native coronary artery









































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Coronary Aneurysm Left Ventricular Wall Clinically Cause of Death Dilated
Case Age (Years) Gender CA With Aneurysm (n) Diameter (cm) Length (cm) Maximal Diameter (cm) First 1 cm of RCA or LMCA Intra-Aneurysmal Thrombus Maximal Luminal Narrowing at Aneurysm (CSA) Atherosclerosis in Aneurysmal Wall Maximal Narrowing of Nonaneurysmal CAs Number of Major CAs ↓ >75% in CSA by Plaque Heart Weight (g) N Fib AP AMI CHF SD SH DAA AAA C Non-C, V Non-C, Non-V RV LV
1 17 F LAD (1) 1.5 1.8 0.4 0 0 0 0 0 — 0 0 0 0 0 + 0 0 0 + 0 0 0 0
2 37 M LC (1) 3.0 Saccular 0.5 0 0 0 0 0 420 0 0 0 0 0 + 0 0 0 + 0 0 0 0
3 41 M R (1) 1.0 1.0 0.4 + >75% + >75% 3 510 0 + 0 0 0 + + 0 0 + 0 0 + +
4 41 M LAD (1) 1.0 1.5 0.4 + >95% + >75% 2 380 0 0 0 0 0 + 0 0 0 + 0 0 0 0
5 41 M R (2) 2.0 4.0 0.5 + >95% + >75% 1 375 + + 0 + 0 + 0 0 0 + 0 0 + +
LAD (2) 1.5 4.0 0 0 + 26%–50%
LC (1) 1.5 3.0 0 0 + 26%–50%
6 42 M LAD (1) 2.0 4.0 0.5 + >75% + 51%–75% 0 500 0 0 0 0 0 0 + + 0 0 + 0 0 0
7 50 M R (1) 1.0 2.0 0.4 + >95% + >75% 3 460 0 + 0 0 0 + − 0 0 + 0 0 0 +
LC (1) 0.9 1.5 + >95% +
8 54 M R (1) 1.5 8.0 0.5 + >75% + >75% 3 400 0 + 0 + + + 0 0 0 + 0 0 + +
LAD (1) 1.5 4.0 + >75% +
9 55 M R (1) 1.5 3.0 0.4 + >95% + >75% 3 450 + 0 + + 0 0 + 0 + + 0 0 + +
10 56 M R (1) 1.3 2.2 0.4 + >95% + >75% 3 510 0 + + 0 0 0 + 0 + 0 0 + 0 +
LAD (1) 2.3 3.0 + >95% +
11 61 M R (1) 2.0 3.5 0.4 + >95% + >75% 1 380 0 + 0 + 0 0 0 0 0 0 0 + + +
12 65 M R (1) 1.1 7.0 0.5 0 51–75% + >75% 2 910 0 + 0 + + 0 + 0 0 + 0 0 + +
LAD (1) 1.0 1.5 0 51–75% +
13 68 M LAD (1) ⁎ 1.5 2.0 0.5 + >75% + >75% 3 560 0 + 0 0 0 0 + 0 0 0 0 + + +
LC (1) ⁎ 2.0 2.0 + >75% +
14 68 F R (1) 2.5 2.2 0.6 + >95% + >75% 2 490 0 0 0 0 0 0 + 0 + 0 0 + 0 0
15 70 M R (1) 5.0 7.0 0.5 + >75% + >75%
LAD (1) 2.0 3.0 + >75% + >75% 3 750 + 0 0 0 0 0 + 0 0 0 0 + 0 0
LC (1) 4.0 3.0 + >75% + >75%
16 70 M LC (1) † 2.5 9.0 0.5 0 0 0 <25% 0 420 0 0 0 0 0 0 + 0 0 0 0 + 0 0
17 72 F R (2) 1.3 3.0 0.4 + >75% + >75% 3 390 0 0 0 0 0 + + 0 0 + 0 0 0 0
LAD (1) 1.3 2.0 + >75% + >75%
LC (1) 1.4 2.0 + >75% + >75%
18 74 F R (1) 2.0 4.0 0.5 + >75% + >75% 2 390 0 0 0 0 0 0 + 0 0 0 0 + 0 0
LC (1) 2.0 2.5 + >75% +
19 84 M R (1) 8.0 10.0 0.7 + >75% + >75% 3 — 0 + + + + 0 + 0 0 + 0 0 0 +
LAD (1) 5.0 3.5 + >75% + >75%
LC (1) 6.0 2.5 + >75% + >75%
20 85 F LAD (1) 1.5 2.0 0.4 + >75% + >75% 2 420 + 0 0 + 0 0 + 0 0 + 0 0 + +

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Dec 16, 2016 | Posted by in CARDIOLOGY | Comments Off on Natural History, Clinical Consequences, and Morphologic Features of Coronary Arterial Aneurysms in Adults

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