Cardiovascular Journal of Africa: Vol 27 No 4 (July/August 2016)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 27, No 4, July/August 2016 e10 AFRICA
Case Report
Simultaneous presentation of giant aneurysms of the
coronary sinus and superior vena cava
Yan Cheng, Huanhuan Gao, Zhelan Zheng, Yun Mou
Abstract
Aneurysms of the coronary sinus and superior vena cava are
rare and their aetiologies remain controversial. Some studies
have shown that these acquired venous aneurysms are caused
by an increase in right atrial pressure, which may be related
to right heart failure. However, few reports have provided
direct evidence to support this hypothesis. We present a rare
case of combined giant aneurysms of the coronary sinus and
vena cava, diagnosed using multiple imaging modalities. This
case strongly supports the hypothesis that right heart dias-
tolic failure may be an important mechanism underlying the
pathogenesis of combined giant aneurysms.
Keywords: aneurysm, coronary sinus, superior vena cava, right
heart failure
Submitted 2/11/15, accepted 11/3/16
Published online 12/4/16
Cardiovasc J Afr 2016; 27: e10–e13
DOI: 10.5830/CVJA-2016-031
Venous aneurysms are rare and the simultaneous presentation of
aneurysms localised in the coronary sinus (CS) and superior vena
cava (SVC) has not been previously reported. Venous aneurysms
may be congenital or secondary to anomalous drainage.1,2
Some studies have shown that acquired venous aneurysms
are most likely caused by an increase in right atrial pressure and
right heart failure.3 However few reports have provided direct
evidence supporting this pathogenic mechanism.
Here, we present a case of giant aneurysms localised in
both the CS and SVC. Our case provides strong evidence for
the possible role of longstanding right heart failure during the
pathogenesis of combined giant venous aneurysms.
Case report
A 22-year-old woman was referred to our hospital because of a
large mass in the left thorax, detected on chest X-ray. She had
a long history of constrictive pericarditis and had undergone
pericardiectomy seven years earlier.
On presentation, a physical examination revealed severe facial
and lower-extremity oedema, hepatomegaly and ascites. She had
no cardiac murmur and no cyanosis, with an oxygen saturation
of 96.6% on room air.
Transthoracic echocardiography showed an enlarged right
atrium and a huge cavity behind the left heart (Fig. 1A). Pulsed-
wave Doppler identified a restrictive transmitral inflow pattern.
Tissue Doppler imaging (TDI) velocities at the septal mitral
annulus showed that early diastolic myocardial velocity (e′)
and systolic myocardial velocity (s′) were 5.85 and 10.4 cm/s,
respectively (Fig. 1B).
Transoesophageal echocardiography revealed a large cystic
cavity with spontaneous echo contrast attached to the posterior
wall of the left heart and communication with the right atrium.
Colour Doppler flow imaging demonstrated a to-and-fro flow
between the cavity and right atrium (Fig. 2A). Contrast-
enhanced computed tomography (CT) showed a giant cavity
(10.4 × 7.3 cm) connected with three cardiac veins (Fig. 3A)
and revealed that it was an aneurysm of the CS. Moreover, CT
showed no evidence of pericardial calcification or thickening.
CT also revealed a dilated inferior vena cava (IVC), aneurysmal
dilated SVC (7.4-cm diameter, Fig. 3B), and a thrombus in the
SVC and left inferior pulmonary artery.
Cardiac catheterisation showed the shape of the CS aneurysm
(Fig. 2B). The right heart pressure was recorded, including
pulmonary arterial pressure (25/22 mmHg), right ventricular
pressure (25/21 mmHg), mean right atrial pressure (23 mmHg)
and mean CS aneurysm pressure (22 mmHg). The family
declined a request for limited biopsy. No other associated cardiac
abnormalities or defects were noted.
Based on the TDI evidence of intact active relaxation and
the presence of diastolic equalisation of pressures, it was
decided that right heart diastolic failure was the dominant factor
contributing to the patient’s symptoms.
We reviewed the patient’s earlier images. Transthoracic
echocardiography performed four years prior to presentation
showed that the aneurysmal dilated CS was 5 cm in diameter
(Fig. 4B) and the dilated SVC was 3 cm in diameter. Septal mitral
annulus e′ and s′ velocity were 6.54 and 19.5 cm/s, respectively
(Fig. 4A). These features suggested that the patient had had a
long history of right heart diastolic failure, and this may have
contributed to the progression of the combined giant aneurysms.
Echocardiography and Vascular Ultrasound Centre, the
First Affiliated Hospital, College of Medicine, Zhejiang
University, Hangzhou, China
Yan Cheng, MD
Huanhuan Gao, MD
Zhelan Zheng, PhD
Yun Mou, PhD,