Giant atherosclerotic left main coronary artery aneurysm: from revascularization to heart transplantation

Coronary artery aneurysms (CAAs) are uncommon vascular anomalies, with an estimated prevalence of 0.3-4.9% in the general population undergoing coronary angiography [1] and are defined as a dilatation of the coronary artery exceeding 50% of the reference vessel diameter. CAAs are termed giant if they are > 8 mm in diameter or greater than 4 times the reference vessel diameter [1]. CAAs are found most frequently in the proximal and middle segments of the right coronary (68%), left anterior descending (LAD) (60%) and left circumflex (50%) artery. CAAs of the left main coronary artery (LMCA) are extremely rare occurring in only 0.1% of the population and carry a high risk of acute myocardial infarction, arrhythmias, and sudden cardiac death. Management of LM-CAA is challenging due to the risk of thrombosis, rupture, and severe myocardial ischemia. While percutaneous interventions may be considered in selected cases, surgical revascularization remains the gold standard for large or complex aneurysms, particularly when associated with significant stenotic lesions. In cases of severe ventricular dysfunction refractory to mechanical support, heart transplantation (HT) may become the only life-saving option [2]. Here, we present a case of an adult patient with a giant LM-CCA complicated by cardiac arrest and cardiogenic shock, who underwent coronary artery bypass-grafting (CABG) and was subsequently successfully managed with emergent HT.