Surgical Repair of a Giant Sinoatrial Nodal Artery Aneurysm

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Coronary artery aneurysms are observed in up to 5 percent of patients undergoing coronary angiography (1). While most coronary artery aneurysms remain asymptomatic and are discovered incidentally during coronary angiography or computed tomography, clinical symptoms may arise due to coexisting obstructive atherosclerotic disease. This can lead to effort angina or acute coronary syndrome, or local thrombosis within the aneurysmal lumen, potentially causing distal embolization and infarction (2,3). 

In this video, the authors present the case of a 64-year-old male with a history of hypertension and heart failure with reduced ejection fraction, who presented with increasing fatigue, malaise, and bilateral lower extremity edema. A coronary angiogram revealed a normal left coronary system but an aberrant right coronary system with a significantly dilated sinoatrial nodal artery. Coronary computed tomography showed that the right coronary artery originated from the right coronary sinus, with a markedly dilated, tortuous sinoatrial nodal artery opening into the sinus venarum. The operation had significant challenges due to the aneurysm's proximity to the sternum, which raised the risk of rupture during sternotomy and the potential for entry into the right atrium due to possible fistulization. As a result, bicaval cannulation was planned, and external pacing leads were prepared in case of bradycardia. Prebypass transesophageal echocardiography revealed multiple lobulations within the aneurysm, and the saline test confirmed no connection between the aneurysm and the cardiac chambers. Initially, a silicone vessel loop was placed around the aneurysmal neck, and transesophageal echocardiogram was used to confirm depression of the aneurysm upon manipulation. The lower aneurysmal sac was first entered from its base and dissected upward to the upper sac, allowing access to both sacs. A blood sucker was used to assess sac connections, which were identified by the flow of blood into the sacs. The entry points were then closed with 5-0 Prolene sutures, and the entry from the right coronary artery was carefully sutured to avoid damage to the artery. Finally, the connection between the two lobulations was sutured closed, ensuring no openings remained. The patient was successfully weaned off cardiopulmonary bypass without arrhythmias. His postoperative course was uneventful, and he remained in sinus rhythm until developing atrial fibrillation on postoperative day three, which was treated with intravenous amiodarone. He was discharged on postoperative day six with aspirin and apixaban to prevent further arrhythmias. . 

Giant coronary artery aneurysms are rare and present a significant surgical challenge. Preoperative imaging using multiple modalities is essential for effective operative planning, while selecting an appropriate cannulation strategy helps mitigate potential complications. Intraoperative transesophageal echocardiogram is crucial for evaluating the aneurysm's anatomy and flow dynamics, ensuring a successful repair. 

References

1. Swaye PS, Fisher LD, Litwin P, Vignola PA, Judkins MP, Kemp HG, Mudd JG, Gosselin AJ. Aneurysmal coronary artery disease. Circulation. 1983 Jan;67(1):134-8.
2. Chrissoheris MP, Donohue TJ, Young RS, Ghantous A. Coronary artery aneurysms. Cardiol Rev. 2008 May-Jun;16(3):116-23.
3. Rath S, Har-Zahav Y, Battler A, Agranat O, Rotstein Z, Rabinowitz B, Neufeld HN. Fate of nonobstructive aneurysmatic coronary artery disease: angiographic and clinical follow-up report. Am Heart J. 1985 Apr;109(4):785-91.

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