Acute myocardial infarction due to giant coronary artery aneurysm and arteriovenous fistula: a challenging case report and review of the literature.

BACKGROUND: A coronary artery aneurysm (CAA) is an abnormal dilation of a coronary artery segment often accompanied by coronary artery fistula (CAF), leading to communication between a coronary artery and a cardiac chamber or a part of the coronary venous system. Both CAAs and CAFs can present with symptoms and signs of myocardial ischemia and infarction. CASE PRESENTATION: We describe the case of a 46-year-old woman with non-ST-elevation myocardial infarction (NSTEMI) caused by a "giant" CAA. Various imaging modalities revealed a thrombus-containing aneurysm located at the right-posterior cardiac border, with established arteriovenous communication with the distal part of left circumflex artery (LCx). After initial treatment with dual antiplatelet therapy, a relapse of pain was reported along with a new increase in troponin levels, electrocardiographic abnormalities, reduced left ventricular ejection fraction (LVEF) and thrombus enlargement. Surgical excision of the aneurysm was favored, revealing its true size of 6 cm in diameter. Τhe aneurysm was excised without complications. The patient remained asymptomatic during follow-up. CONCLUSIONS: Management of rare entities such as "giant" CAAs and CAFs can be challenging. Cases such as this can serve as precedents to facilitate treatment plans and develop consistent recommendations, emphasizing the importance of personalized strategies for future patients.

Acute aortic dissection type A: case series and insights on incidence, management and outcomes.

BACKGROUND: Acute aortic dissection (AAD) is a life-threatening condition with high mortality rates, despite significant advances in surgical approaches. The understanding of the clinical presentation and outcomes is crucial in order to upgrade management strategies. However, epidemiological data regarding AAD occurrence are scarce in Europe, highlighting the gap of evidence in the existing guidelines. CASE SERIES: We investigated 197 consecutive patients admitted to our institution from January 2018 to December 2019 with suspicion of type A AAD, conducting a retrospective case series. All demographic characteristics, as well as the outcomes of these patients, were recorded and further analyzed to deliver data on the epidemiology of AAD. A total of 197 patients were admitted to our hospital with a suspected AAD. Forty-one (25.9 %) patients presented with a dilated aortic lumen or with a previously repaired aortic dissection, while 28 patients (14.2 %) were diagnosed with AAD (14 patients with type A AAD, 13 with type B AAD and 1 with intramural hematoma). Among 14 patients with type A AAD, nine patients (64.0 %) were treated surgically, while the rest were managed conservatively due to futile clinical status or inability for immediate transportation to a surgical facility. The most frequent initial symptom was chest pain in 86.0 % of patients, followed by dyspnea in 42.9 %. Post-surgical mortality was 33.0 %, while all patients that were managed conservatively did not survive. D-dimers on arrival were significantly lower among patients who survived compared to those who did not. CONCLUSION: The incidence of type A AAD in our case series was consistent with the one demonstrated in other international cohorts; however, the mortality in our patient group was higher. Our results encourage surgical treatment due to a lower in-hospital mortality rate when compared to conservative treatment. HIPPOKRATIA 2021, 25 (1):42-46.