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Aloha!\xa0CardioNerds\xa0(Amit Goyal\xa0&\xa0Karan Desai)\xa0 join University of Hawaii cardiology fellows (Isaac Mizrahi, Nath\xa0Limpruttidham, Nishant Trivedi, and Shana Greif) for some shaved iced on the Big Island's north shore! They discuss a fascinating case of a patient presenting with decompensated heart failure found to have a giant coronary aneurysm. Program director Dr. Dipanjan Banerjee provides the E-CPR as\xa0well as a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident\xa0Tommy Das\xa0with mentorship from University of Maryland cardiology fellow\xa0Karan Desai.\xa0\xa0\n\n\n\n\n\nJump to: Patient summary - Case media - Case teaching - References \n\n\n\nEpisode graphic by Dr. Carine Hamo\n\n\n\nCardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza\n\n\n\n\n\n\n\nPatient Summary\n\n\n\nA man in his early 60s with history of hypertension, peripheral arterial disease, atrial fibrillation, and AAA s/p repair presented with subacute fatigue, palpitations, shortness of breath, and lower extremity edema. On exam he was warm and well perfused, though hypotensive, tachycardic with an irregular rhythm, and had an elevated JVP. ECG showed AF with RVR without evidence of acute MI, and troponin was negative. TTE revealed a reduced LVEF and WMA in the inferolateral walls with akinesis of the basal mid septum; additionally, two large extracardiac structures were noted, one with heterogenous echotexture in the AV groove, and a second with an echolucent interior adjacent to the RA.\n\n\n\nThe patient underwent coronary angiography, showing a dilated and calcified proximal LAD with high grade stenosis adjacent to the first septal perforator, a ectatic LCX that supplied left to right collaterals, and a giant RCA aneurysm with TIMI 0 flow distally. CCTA confirmed these findings, showing thrombosed aneurysms of the LAD, LCX, and RCA. Interventional cardiology and cardiac surgery both evaluated the patient's case, and determined that he was not a candidate for intervention. He was ultimately diuresed to euvolemia with significant improvement in symptoms, and plans to follow-up as an outpatient for heart transplant evaluation.\n\n\n\n\n\n\n\nCase Media\n\n\n\n\nABCDClick to Enlarge\n\n\n\nA. CXRB. ECG: atrial fibrillation with RVR, left axis deviation, poor r wave progressionC. Wide complex tachycardia D. CT chest demonstrating giant aneurysm \n\n\n\n\n\nTTE\n\n\n\n\n\nCoronary Angiography\n\n\n\n\n\n\n\n\n\n\nEpisode Schematics & Teaching\n\n\n\nThe CardioNerds 5! \u2013 5 major takeaways from the #CNCR case\n\n\n\n1)\xa0This case featured a patient with a giant coronary aneurysm \u2013 how are coronary artery aneurysms defined and classified?\xa0\xa0\n\n\n\nCoronary artery aneurysms (CAA) are defined as a focal dilation of a coronary segment at least 1.5x the adjacent normal segment. Contrast this with coronary artery ectasia, which refers to a diffuse, as opposed to focal, coronary\xa0dilation.\xa0\xa0CAA morphology can be classified as either\xa0saccular (transverse > longitudinal diameter) or fusiform (transverse < longitudinal diameter).\xa0Giant CAA's are >20mm in diameter.\xa0Aortocoronary saphenous vein\xa0graft\xa0aneurysms have distinct characteristics and natural history compared to native coronary aneurysms. These aneurysms tend to present late (e.g., > 10 years following CABG) and tend to be larger than native CAA.\xa0IVUS can help differentiate between a true aneurysm with preserved integrity of all 3 vessel layers (intima, media, and adventitia) and a pseudoaneurysm with loss of wall integrity and damage to the adventitia.\xa0\n\n\n\n2) Now that we have the language to define and classify coronary artery aneurysms, what are some causes these lesions?\xa0\xa0\n\n\n\nAtherosclerosis:\xa0lipid deposition, focal calcification, and fibrosis can weaken the vessel wall and predispose\xa0to\xa0subsequent coronary artery dilation. Up to 50% of CAAs are linked to arteriosclerosis.