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IMAGES IN CARDIOLOGY

Polyarteritis Nodosa Causing aVast Coronary Artery Aneurysm

Ullrich Ebersberger, MD,* Johannes Rieber, MD,* Petra Wellmann, MD,y Constanze Goebel, MD,zBrigitte Gansera, MDy

A 35-year-old Caucasian female with a historyof systemic vasculitis and suspicion of poly-arteritis nodosa was referred for evaluation

of recurrent chest pain. The echocardiogram showed

FIGURE 1 Multimodal Imaging of a Patient With Polyarteritis Nodos

(A) Echocardiogram shows a 30 mm wide hypoechoic structure lateral to

right coronary aneurysm (arrow) using coronary angiography (B). Pre-o

angiography revealed a second inguinal aneurysm (arrow, D). See accom

RV ¼ right ventricular.

From the *Department of Cardiology and Intensive Care Medicine, Heart Ce

Germany; yDepartment of Cardiovascular Surgery, Heart Center Bogenhausen

zDepartment of Rheumatology, Klinikum Bogenhausen, Munich, German

relationships relevant to the contents of this paper to disclose. Drs. Ebersbe

Manuscript received June 26, 2013; revised manuscript received August 3, 2

a normal left ventricular ejection fraction and anambiguous 30-mm-wide hypoechoic structure lateralto the right atrium (Figure 1A). Cardiac catheterization(Figure 1B, Online Video 1) revealed a vast aneurysm of

a and Recurrent Chest Pain

the right atrium (arrow). The structure is diagnosed as 30 x 40 mm

perative CT confirmed the large coronary aneurysm (arrow, C). MRI

panying Online Video 1. LV ¼ left ventricular; RA ¼ right atrial;

nter Bogenhausen, Klinikum Bogenhausen, Munich,

, Klinikum Bogenhausen, Munich, Germany; and the

y. The authors have reported that they have no

rger and Rieber are joint first authors.

013, accepted August 13, 2013.

FIGURE 2 Operative Situs and Histological Stains of a Vast Coronary Artery Aneurysm

(A) Operative view of the huge right coronary aneurysm (arrow). (B) Operative situs before

resection of the coronary aneurysm. Noticeable is the intraluminal thrombotic material

(arrow). (C) H&E stained section (1:40) of the coronary artery aneurysm. Pattern of an acute

phase panarteriitis with transmural inflammatory infiltration and an enlargement of the artery

wall. The discrimination of the layering is decreased due to the inflammatory process.

(D) 180 � magnification of the Tunica media with multiple granulocytes and histiocytes.

Ebersberger et al. J A C C V O L . 6 5 , N O . 5 , 2 0 1 5

Vast Coronary Aneurysm F E B R U A R Y 1 0 , 2 0 1 5 : e 1 - 2

e2

the right coronary artery. Pre-operative computed to-mography confirmed the finding of a coronary aneu-rysm (Figure 1C), and magnetic resonance imagingangiography revealed a second inguinal aneurysm(Figure 1D). Due to the potential inflammatory involve-ment of the internal thoracic artery, a single coronaryartery bypass using a saphenous vein graft was per-formed without complications. Intraoperatively,thrombotic material was observed within the aneu-rysm (Figures 2A and 2B). Thepatientwas extubateddur-ing the first day. On the second post-operative day,she was transferred in stable condition to the cardiacsurgical ward. On histological examination, a hema-toxylin and eosin–stained section of the coronaryartery aneurysm showed transmural inflammatorynecrotic and fibrotic infiltrations consistent with thediagnosis of polyarteritis nodosa (Figures 2C and 2D).Treatment with intravenous cyclophosphamide wasinitiated, and the patient was discharged in goodcondition to rehabilitation.

NOTIFICATION JACC is publishing 3 “Images in Cardiology”articles in this issue. These manuscripts were accepted prior tothe current editorial administration. Please note that they are nolonger a standard manuscript type that will be acceptable by theJournal.