Discussion
The pathogeny of coronary artery aneurysm includes atherosclerosis,
Kawasaki disease, inflammation, trauma, infection, connective tissue
disease and so on[5]. Even though atherosclerosis
is the most common cause of CAA in adult[5], the
patient in this case has no evidence of atherosclerosis. The cause of
CAA in this patient may mostly be Kawasaki disease or congenital
abnormality, with the evidence of the multiple coronary artery aneurysms
and the negative serology investigations.
Anomalous origin of the coronary artery (AOCA) associated with sudden
cardiac death and myocardial ischemia[3]. The
presented hypotheses about sudden cardiac death were based on anatomic
and physiologic properties of the anomalous coronary, while the
triggering factors of the myocardial ischemia may be the insufficient
coronary reserve[3].
The CAA and AOCA, both of the coronary anomalies are asymptomatic
usually, just abnormal electrocardiogram was shown[2,
3]. In this case, the patient has chest pain symptom and abnormal
electrocardiogram. Multimodality imaging plays a vital role in
developing optimal management by revealing giant CAAs combined with
anomalous aortic origin of left coronary artery, but also providing
detailed information of coronary artery, myocardial wall contraction and
the cardiac hemodynamics. Coronary angiography is useful in evaluating
stenosis degree of coronary artery and compensative collateral
circulation, while the overlook of CAAs and its relationship with
adjacent constitution was not clear. CTA displayed multiple CAA
scattered throughout the right coronary artery and anomalous origin of
the left coronary artery arises from sinotubular junction. In delayed
enhancement sequence, CMR detects the thrombus contained in some
coronary artery aneurysms. Transthoracic echocardiography provides
information about the change of cardiac hemodynamics, abnormal motion of
ventricular wall, and the effects of giant CAAs on cardiac structure and
function.
Based on the anatomic subtypes of AAOCA and characteristics of giant
CAAs, it is necessary to develop individualized treatment plan based on
the detailed information of coronary artery. In this case, multimodality
imaging indicated that the patient had intervention indication. Then,
coronary artery bypass graft surgery was performed, and he recovered
uneventfully and no major adverse cardiac events were reported during
the 6-months follow-up.