Case report
A 30-years old man was presented with exertional chest pain repeatedly,
without hypertension and dyslipidemia. On physical examination, his
blood pressure was 105/55mmHg, heart rate is 70 bpm, cardiac murmur was
not obvious. Electrocardiogram showed the sign of ischemia in inferior
wall and previous infarction in interventricular septum. Hypersensitive
troponin I level was 37.5 ng/L, the blood NT-ProBNP level was 376.0
pg/ml, the inflammatory markers were normal. Transthoracic
echocardiography(TTE) found an enlarged mass (5.1×4.3cm) close to right
coronary artery opening, with thrombus contained probably and no flow
signal inside, compressing the anterior part of tricuspid annular and
right ventricle without abnormal hemodynamics (Figure 1A and B). Besides
of that, the decreased motion of middle segment anterior septal wall was
detected by TTE. Coronary angiography showed that there were multiple
aneurysms in proximal and middle part of right coronary artery (RCA),
but distal part of RCA can’t be displayed (Figure 2A). The left anterior
descending (LAD) and left circumflex artery (LCX) were occluded in
proximal part, and collateral
circulation was developed around (Figure 2B). To clearly displaying the
distal part of RCA, CCTA was performed and found a string of aneurysms
distributed in distal part of RCA (Figure 3A). Unexpectedly, CCTA found
the origin of left coronary artery was abnormal, which arising from left
side of sinotubular junction and part of left main coronary arteries
distributing between the ascending aorta and the main pulmonary artery
(Figure 3B). CMR found some of aneurysms had thrombose inside (Figure
3C), and distinctly displayed the course of left main coronary arteries
distributing between two arteries (Figure 3D). Taken imaging
characteristics of coronary artery into consideration, the diagnosis
mostly be suspected as multiple giant right coronary artery aneurysms
with thrombus combined with anomalous aortic origin of left coronary
artery. Finally, coronary artery bypass graft surgery was performed, and
intraoperative finding demonstrated the suspected diagnosis. In the
intraoperative view, there were two giant coronary artery aneurysms with
thrombus adjacent to each other in proximal and mid part of right
coronary artery (Figure 4).