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.