Giant Coronary Artery Aneurysms and Severe Biventricular Failure: Multimodality Imaging-Guided Conservative Management.

BACKGROUND: Giant coronary artery aneurysms are rare vascular abnormalities associated with thrombosis, myocardial ischemia, and heart failure and lack standardized management strategies. CASE SUMMARY: A 35-year-old man presented with acute heart failure. Transthoracic echocardiography revealed severe biventricular dysfunction and a large paracardiac mass. Coronary computed tomography angiography demonstrated multivessel giant coronary artery aneurysms with mural thrombi involving all epicardial vessels. Cardiac magnetic resonance demonstrated transmural late gadolinium enhancement confined to the anterior and lateral walls, with partial recovery of biventricular function. Following Heart Team evaluation, conservative management with guideline-directed medical therapy, anticoagulation, and imaging surveillance achieved reverse remodeling and aneurysmal stability at 16-month follow-up. DISCUSSION: This case highlights the role of multimodality imaging in guiding therapeutic decision-making and conservative management in complex giant coronary artery aneurysms. TAKE-HOME MESSAGE: Management requires individualized Heart Team decision-making and structured imaging surveillance; initial conservative therapy may achieve reverse remodeling in selected patients.