Conservative Management of Giant Aneurysm of the Left Main to Left Circumflex Arteries

Coronary artery aneurysm (CAA) is a rare congenital or acquired coronary malformation, associated with coronary artery fistula (CAF) in approximately 15% of cases. CAA is often asymptomatic. We report the case of a 60-year-old woman diagnosed in 2017 with a 15-mm large giant left main to left circumflex CAA. In 2024, she presented with progressive dyspnea. Multimodality imaging revealed severe mitral valve regurgitation and giant CAA associated with a distal CAF. After comprehensive evaluation, the heart team opted for mitral valve surgery and conservative CAA management. After 9-month follow-up, she remains uneventful. Management of giant CAA is controversial. Surgery remains the gold standard treatment, yet particularly challenging. It is mainly recommended for symptomatic patients, with evidence of ischemia or a significant left-to-right shunt. Conservative therapy remains a valuable option in asymptomatic cases, provided that close follow-up is ensured. Multimodal imaging is crucial for diagnosis, management, and surveillance.