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Findings: PA chest film (not included) demonstrated cardiomegaly, cephalization of the pulmonary flow pattern, interstitial edema, and Kerley B-lines consistent with congestive heart failure. On the lateral chest film there is a tubular calcification involving the anterior aspect of the heart shadow with a width of 2 cm. (Image 1). The calcification was not visible on the PA chest. Because of this finding a CT scan was obtained. The CT scan demonstrates coronary artery calcification with an aneurysm of the right coronary artery (Images 2 and 3).
Diagnosis: Aneurysm of the right coronary artery.
Discussion: Aneurysms of the right coronary artery have been observed in 1.4% of an autopsy series and 1.5% of a series of patients undergoing coronary angiography. These aneurysms are due to atherosclerosis, infection, trauma, syphilis, vasculitis, and rarely can be congenital. Most of these patients will be asymptomatic although some may have symptoms of coronary artery disease. There are no definitive physical findings for a coronary artery aneurysm although systolic and diastolic heart murmurs have been reported. Because of the possibility of thrombosis or rupture, it has been recommended that these aneurysms be removed and coronary artery bypass grafts be placed. If the aneurysm is small or diffuse, then surgery is not recommended.
Differential diagnosis of the plain film findings could include other causes of calcification of the heart such as myocardial infarction, myocardial aneurysm, or cardiac tumor.
References:
Pennington DG, Willman VL. "Anomalies of the Coronary Vessels"
In: Glenn's Thoracic and Cardiovascular Surgery. 6th Edition, Appleton
and Lange. 1996; 2:1529.
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