PMC5896253_01
(a, b) 2D Echocardiogram showing echolucent mass in the right AV groove with mass effect. AV: atrioventricular.
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Retrospectively, a transthoracic echocardiogram (TTE) performed 4 years prior had demonstrated an echolucent mass external to the heart located in the right atrioventricular junction causing mass effect on the right atrium and ventricle (Figure 1); however, it was not investigated further.
CT coronary angiogram. Thrombosed RCA aneurysm in coronal (a) and axial (b) view in right AV groove. (c) Curved multiplanar reformatted image displaying full length of the RCA. AV: atrioventricular; RCA: right coronary artery.
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It showed a large encapsulated spherical mass with wall thickening in the right atrioventricular groove measuring 38.6 mm by 47.4 mm, continuous with the right coronary artery in the mid-occluded mid-right coronary artery (RCA) segment, findings consistent with a thrombosed gRCAA (Figures 2(a)-2(c)).
(a, b) Invasive coronary angiogram showing thrombosed RCA aneurysm with contrast and no distal flow. AMB: acute marginal branch; RCA: right coronary artery.
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Coronary angiography confirmed a totally occluded RCA with a mid-RCA dilation that demonstrated contrast swirling in the aneurysm (Figures 3(a) and 3(b)).
Intraoperative surgeons' view of the RCA aneurysm intact (a) and excised (b). (c) Photomicrographs of the fibrin thrombus removed from the RCA aneurysm taken at 40x magnification. Shown is the more mature portion of the thrombus on the right side composed of dense, laminated fibrin, while the luminal side (left) has more recent thrombus deposition composed of blood/platelets alternating with fibrin bands (lines of Zahn). RCA: right coronary artery.
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As such, he underwent a surgical aortic valve replacement with a 27 mm Sorin Solo Smart tissue valve, coronary artery bypass grafting was done using a saphenous vein graft to the distal posterior descending artery with end to side to acute marginal anastomosis, the gRCAA was excised and repaired with over sew of proximal and distal coronary artery (Figures 4(a)-4(c)) with a left atrial appendage amputation for his atrial fibrillation.