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Images in Cardiovascular Medicine Saphenous Vein Graft Aneurysm Causing Pulmonary Artery Compression With Exercise Sarah J. Gutman, MBBS, BMedSci; Jack Gutman, MBBS, FRACP, FCSANZ, DDU; John Vrazas, MBBS, FRANCR, EBIR; Daniel S. Berman, MD A Downloaded from http://circ.ahajournals.org/ by guest on June 14, 2017 77-year-old man presented with dyspnea. A left sternal edge systolic ejection murmur was noted. He had undergone coronary artery bypass grafting with a saphenous vein graft to the left anterior descending artery 34 years earlier, complicated by graft degeneration 10 years later, necessitating repeat surgery (left internal mammary artery to left anterior descending artery). A rest/exercise echocardiogram demonstrated normal rest and exercise left ventricular function with no ischemia. The right ventricle was mildly dilated at rest, with mild systolic impairment and further dilatation and hypokinesis with exercise. The resting right ventricular systolic pressure was 50 mm Hg plus right atrial pressure (RAP), increasing to 100 mm Hg plus RAP with exercise and falling to 60 mm Hg plus RAP after exercise. The pulmonary artery (PA) systolic pressure gradients at rest and exercise were 50 and 95 mm Hg, respectively. Invasive investigations revealed a PA gradient of 20 mm Hg, right ventricular systolic pressure of 40 mm Hg, PA pressure of 20/4 mm Hg, and a large, partially thrombosed aneurysm of the original vein graft (Figure 1). The left internal mammary artery graft to the left anterior descending artery was patent. Computed tomography (Figure 2) confirmed a 6.3 cm graft aneurysm compressing the PA (arrow). Accordingly, the aneurysm was coiled with abolition of flow. His breathlessness subsequently improved. Exercise echocardiography 17 months later revealed normal resting right ventricular systolic pressure (21 mm Hg plus RAP), increasing to 32 mm Hg plus RAP with exercise, with a peak systolic PA gradient at maximum exercise of only 22 mm Hg. This case represents a rare example of a saphenous vein graft aneurysm causing dynamic PA compression as arterial pressure within the aneurysm rose with exercise. Disclosures None. From St. Vincent’s Hospital Melbourne, Department of Cardiology (S.J.G., J.G.) and Department of Radiology (J.V.), Fitzroy, Australia; and CedarsSinai Heart Institute, Los Angeles, CA (D.S.B.). Correspondence to Sarah J. Gutman, MBBS, BMedSci, Cardiac Investigation Unit, St. Vincent’s Hospital, 41 Victoria Parade, Fitzroy, Australia 3065. E-mail [email protected] (Circulation. 2015;132:1681-1682. DOI:10.1161/CIRCULATIONAHA.115.014122.) © 2015 American Heart Association, Inc. Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIRCULATIONAHA.115.014122 1681 1682 Circulation October 27, 2015 Downloaded from http://circ.ahajournals.org/ by guest on June 14, 2017 Figure 1. Coronary angiogram showing an aneurysm in the vein graft. Figure 2. Computed tomography showing the 6.3-cm graft aneurysm (A) compressing the pulmonary artery (P; arrow). Saphenous Vein Graft Aneurysm Causing Pulmonary Artery Compression With Exercise Sarah J. Gutman, Jack Gutman, John Vrazas and Daniel S. Berman Circulation. 2015;132:1681-1682 doi: 10.1161/CIRCULATIONAHA.115.014122 Downloaded from http://circ.ahajournals.org/ by guest on June 14, 2017 Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2015 American Heart Association, Inc. All rights reserved. Print ISSN: 0009-7322. Online ISSN: 1524-4539 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://circ.ahajournals.org/content/132/17/1681 Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Circulation can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Once the online version of the published article for which permission is being requested is located, click Request Permissions in the middle column of the Web page under Services. Further information about this process is available in the Permissions and Rights Question and Answer document. Reprints: Information about reprints can be found online at: http://www.lww.com/reprints Subscriptions: Information about subscribing to Circulation is online at: http://circ.ahajournals.org//subscriptions/