Management of Acute Myocardial Infarction after a Blunt Chest Trauma

Abstract

Coronary artery dissection is a rare complication after blunt chest trauma. Patients usually present with sudden death and the diagnosis is frequently missed. In this report, we present a case of a 46-year-old with a hyperacute anterior wall myocardial infarction after blunt chest trauma. Diagnostic coronary angiography showed total occlusion of the left anterior descending coronary artery (LAD) starting at the takeoff of the vessel from the left main coronary artery (LMCA). A bare-metal stent was immediately deployed at the proximal LAD and TIMI 3 flow was achieved; however post-procedural images revealed no satisfactory results. A proximal dissection and intraluminal thrombus extending to the LMCA was observed. Because of the proximity of the lesion to the LMCA, re-intervention was considered to be risky and urgent coronary artery bypass grafting (CABG) was planned. Coronary artery stenting is the advised treatment modality for coronary occlusion after blunt chest trauma. However, post-traumatic percutaneous coronary intervention was sometimes considered to be risky because of the anatomic features of the lesion. Timing is cardinal in achieving early reperfusion in the course of myocardial infarction after blunt chest trauma and CABG should be the preferred procedure for initial reperfusion treatment especially in proximal LAD dissections with subsequent thrombus formation leading to total occlusion of the artery.Key Words: Chest trauma; coronary artery dissection; percutaneous coronary intervention.Künt göğüs travması sonrası koroner arter diseksiyonu nadir bir komplikasyondur. Hastalar genellikle ani ölüm ile gelirler ve tanı çoğu zaman atlanmaktadır. Bu yazıda künt göğüs travması sonrası hiperakut önyüz miyokart enfarktüsü gelişen 46 yaşında bir olgu sunuldu. Tanısal koroner anjiyografi sol ana koroner arter çıkışından başlayan sol ön inen arterin (LAD) total oklüzyonunu göstermekteydi. Koroner anjiyografi sonrası hızlıca proksimal LAD'ye çıplak stent yerleştirildi ve TIMI 3 akım elde edildi; fakat işlem sonrası görüntüler tatminkâr sonuçlar göstermedi. Proksimal bir diseksiyon ve sol ana koronere yayılan intraluminal trombüs gözlendi. Lezyonun sol ana koroner artere yakınlığından dolayı tekrar girişim riskli bulundu ve acil koroner arter baypas greftleme (CABG) planlandı. Koroner arter stentleme, künt göğüs travması sonrası gelişen koroner tıkanıklıkta tavsiye edilen tedavi yöntemidir. Fakat lezyonun anatomik özelliklerine bağlı olarak perkütan koroner girişim bazen riskli olarak kabul edilmektedir. Künt göğüs travması sonrası miyokart enfarktüsü durumunda erken reperfüzyonun sağlanmasında zamanlama önemlidir ve CABG özellikle damarın total oklüzyonuna yol açan trombüs oluşumu ile birlikte olan proksimal LAD diseksiyonlarında başlangıç reperfüzyon tedavisi için tercih edilen yöntem olmalıdır.Anahtar Sözcükler: Göğüs travması; koroner arter diseksiyonu; perkutan koroner girişim.

ACR Appropriateness Criteria® Blunt Chest Trauma-Suspected Cardiac Injury

“…These findings triggered further imaging and subsequent intervention [21] to treat coronary artery dissection following blunt trauma [39]. Several case reports have described the use of coronary angiography as a diagnostic and therapeutic modality [40,[43][44][45][46] to not only detect coronary artery dissection and thrombosis in patients with ECG abnormalities, or increased serum troponin level, but also treat with angioplasty or coronary artery stent placement. More recently, high-sensitivity cardiac troponins have become the mainstays in an emergency evaluation [7].…”

Ventricular Fibrillation Caused by Traumatic Coronary Artery Dissection

“…These cases appear to indicate that myocardial necrosis is progressing as long as the coronary artery is occluded, even if spontaneous resolution is eventually observed. Therefore, early reperfusion is critical to preventing development into fatal arrhythmia, and can help to protect the myocardium, which can prevent severe pump failure or mechanical complications [8] [11] [16] [17].…”

“…When such intimal tearing exists, balloon angioplasty alone may allow a thrombus to re-form at that site [16]. Moreover, dissection may lead to expansion of the false lumen, which would preclude thrombolysis [4] [7] [17]. Therefore, it is important to differentiate between dissection and simple occlusion in cases of chest trauma, and IVUS appears to be useful for this differentiation.…”

Fatal blunt cardiac injury: are there any subtle indicators?

“…Non-penetrating trauma to the heart or blunt cardiac injury is a well-established pathological entity which is difficult to diagnose, as there are no telltale clinical signs for its identification 1 2. Frequently, the symptoms are non-specific and there are no specific tests to detect myocardial contusion 1.…”