Massive hemopericardium as a first manifestation of coronary aneurysm -----Successful surgical management

Kanji Iga, Takahisa Fujikawa, *Yuichi Ueda, *Shigehito Miki, Takashi Konishi

The leading causes of massive hemopericardium are malignant neoplasm and rupture of a dissecting aneurysm. We describe here a rare case of massive hemopericardium resulting from a ruptured coronary aneurysm. The patient was treated successfully by surgery.

The patient was a 43-year-old female known to have had a continuous murmur for about 18 years. On May 1, 1993, she began a program of jogging 5 km daily. Fifteen days later, she experienced dyspnea during jogging. Dyspnea on effort progressed gradually over the next 2 weeks and paroxysmal nocturnal dyspnea, generalized edema and a 12 kg weight gain ensued. She was admitted to another hospital where massive pericardial effusion and an abnormal channel adjacent to the pulmonary artery were detected by two-dimensional echocardiography. Pericardiocentesis yielded bloody effusion with 19 % hematocrit while the blood hematocrit was 30%. The effusion shifted to the left pleural space after pericardiocentesis and her symptoms improved markedly. She was referred to our hospital for further evaluation and treatment.

On physical examination, the jugular venous pressure was only slightly increased. A grade 3/6 continuous murmur was heard all over the anterior chest wall. An electrocardiogram was normal. Two-dimensional echocardiography showed a moderate amount of pericardial effusion and a normal sized left ventricle. An abnormal channel in which flow signal was observed by Doppler echocardiography and with septa in it was detected adjacent to the main pulmonary artery. Contrast enhanced chest computed tomogram provided an excellent image of the abnormal channel with indentations. Aortography showed a large coronary aneurysm (Fig. 1). On selective coronary angiography, the coronary aneurysm arose from the proximal left anterior descending artery draining into the main pulmonary artery. The left anterior descending artery beyond the aneurysm was normal (Fig. 2). The pulmonary and systemic flow ratio was 1.4. Obliteration of the fistula and resection of the aneurysm without aorto-coronary bypass was done successfully. The origin of the aneurysm proved to be a branch of the left anterio descending artery. The coronary aneurysm disappeared completely after surgery.

The incidence of coronary fistula was approximately 0.18% in 126,955 consecutive coronary angiographies (1). Okita et al reported an abnormal cardiac shadow as the first manifestation of an aneurysm of a coronary fistula filled with thrombus (2). We are aware of only one autopsy report of sudden death in a patient who showed hemopericardium with coronary aneurysm associated with coronary arteriovenous fistula (3).

In our case, paroxysmal nocturnal dyspnea and generalized edema developed after 5 km of jogging for 15 days and the patient was able to pinpoint the exact day that she felt abnormal. Massive hemopericardium was identified and the symptoms markedly improved after pericardiocentesis. Therefore, the first symptoms were presumably due to cardiac tamponade caused by ruptured coronary aneurysm to the pericardium.

The symptoms of coronary arteriovenous fistula usually depend on the degree of left-to-right shunt. Congestive heart failure, angina pectoris due to coronary steal are the established indication for surgery. In a review of 174 cases, early surgery is recommended to lessen future complications even in cases without the above symptoms (4). Egashira et al reported that a coronary aneurysm can develop or enlarge in patientswith a coronary arteriovenous fistula, especially those draining into the pulmonary artery (5). Since the continuous murmur was noted 18 years before, coronary arteriovenous fistula had been present and might have enlarged in these 18 years and the aneurysm finally ruptured under the stress. As the aneurysm originated from a branch of the left anterior descending artery which itself was normal in size, simple obliteration without bypass surgery could be done.

We think that the regular follow-up for enlargement or development of coronary aneurysm is necessary in patients with a coronary-pulmonary fistula.