International Journal of Cardiology 173 (2014) 118–130
Contents lists available at ScienceDirect
International Journal of Cardiology j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j c a r d
Letters to the Editor
Airbag inflation-related left main coronary artery dissection, localized aortic dissection and aortic valve dehiscence in a patient with previous coronary artery surgery☆ Fatih Mehmet Uçar ⁎, Fatih Şen, Murat Karamanlioğli, Kumral Çağli Turkey Yuksek Ihtisas Education and Research Hospital, Ankara, Turkey
a r t i c l e
i n f o
Article history: Received 13 October 2013 Received in revised form 30 December 2013 Accepted 1 January 2014 Available online 1 February 2014 Keywords: Airbag Dissection Dehiscence
Almost 30% of all trauma patients have some form of cardiothoracic injury [1]. The diagnosis of blunt cardiac injury can be challenging because chemical markers, nuclear studies and echocardiograms rarely correlate with the severity of injury. Combination of coronary artery injury, aortic dissection and acute aortic valve rupture after blunt chest trauma is very rare but can be rapidly fatal and requires prompt recognition and treatment. In this report we describe a case of a male patient who had an airbag inflated car crash that resulted in a left main coronary artery (LMCA) dissection, localized aortic dissection and dehiscence of aortic valve commissure. A 60 year-old male patient with a 2-day history of car crash was transferred to our hospital for evaluation of refractory chest pain. The patient has been the driver of the car and hit a wall after losing the control of the car due to going too fast. The crash has resulted in the inflation of the front driver's airbag that was followed by a sudden retrosternal chest pain without any penetrating injury. He was admitted to a local hospital first but since he had refractory chest pain and troponin positivity, he was transferred to our hospital. His past medical history was remarkable for coronary artery bypass surgery (left internal mammary artery (LIMA) to left anterior descending artery (LAD)) that was performed 7 years ago. On admission, his blood pressure was 120/75 mm Hg, heart rate was 95 beats per minute, and respiration rate was 20 per minute. Carotid and
☆ This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-No Derivative Works License, which permits non-commercial use, distribution, and reproduction in any medium, provided the original author and source are credited. PII of original article: . ⁎ Corresponding author. Tel.: +90 5543459797.
jugular venous pulsations were normal. Palpation of the anterior chest wall, especially the sternal area was painful but auscultation of the lungs was normal. The first and second heart sounds were normal with a 2/6 diastolic murmur along the right sternal border. There were no signs and symptoms of abdominal injury and fractures of extremity. Surface electrocardiogram revealed sinus rhythm and STsegment depression and T-wave inversion in leads V3–V6. Chest X-ray showed uncomplicated fractures of ribs and sternum with a normal cardiothoracic ratio. His cardiac biomarkers were found to be elevated (creatinine phosphokinase-MB: 135 ng/mL (b3 ng/mL) and troponin: 2.1 ng/mL (b0.04)). Transthoracic echocardiography showed mild to moderate aortic regurgitation and a reduced left ventricular ejection fraction (EF 40%) with akinesia of apical segments. He underwent selective coronary angiography which revealed a Type A dissection of the LMCA that extended to the proximal LAD (Fig. 1, Video-1) with a patent LIMA–LAD bypass and TIMI 3 distal flow. His aortogram demonstrated a short dissection flap in the ascending aorta just above the aortic valve (Fig. 2, Video-2). Transesophageal echocardiography (TEE) revealed dehiscence of the non-coronary cusp of the aortic valve that resulted in a mildlymoderate aortic regurgitation and a 9 mm sized intimal flap in the ascending aorta just above the non-coronary cusp (Video-3).
Fig. 1. Dissection of the left main coronary artery image demonstrated by angiogram.
Letters to the Editor
Fig. 2. Localized aortic dissection of the ascending aorta image demonstrated by angiogram.
Thoracoabdominal computed tomographic angiography confirmed the diagnosis of traumatic aortic dissection in the ascending aorta without any extension beyond the sinotubular junction (Fig. 3). Blunt chest trauma may result in various cardiovascular injuries. The most common injury after blunt chest trauma is myocardial contusion. Coronary artery dissection is a rare condition which accounts for 15.8% of myocardial infarction due to blunt chest trauma [2]. Dissection most often occurs in the left anterior descending artery [3], followed by the right coronary artery [4]. Although rare, left main coronary artery involvement has also been reported. Mechanisms of acute myocardial infarction following traumainduced coronary artery dissection are unclear, but shearing forces during the traumatic episode may produce a small intimal tear which subsequently initiates the process of thrombus formation. Thrombolytic therapy for the acute phase of these patients is controversial because it
may worsen the dissection itself. Treatment of coronary artery dissection patients, conservative management, percutaneous interventions or CABG are recommended. Aortic valve dehiscence with localized aortic dissection resulting in acute aortic insufficiency is an uncommon complication of blunt chest trauma. Sudden increase in intrathoracic pressure is the mechanism of dissection and dehiscence. Nearly all authors recommend that surgical intervention be done as soon as possible in such cases. In our patient, we decided to proceed to surgery. Laceration of an aortic valve cusp and aortic dissection were treated successfully with urgent surgery. Surgeons removed as much of the dissected aorta as possible, blocked the entry of blood into the aortic wall and reconstructed the aorta with a synthetic tube called a graft than the valve is placed within the graft that is used to reconstruct the aorta. LMCA dissection was treated conservatively and discharged without serious sequelae. The automotive safety systems are playing an important role in saving lives during crashes. One such device is the airbag which has become a standard equipment in all automobiles and is generally assumed to improve driver and passenger safety in the event of a crash. Although the airbag affords valuable protection against crushing injuries of the head and body, it can cause other, less apparent, blunt trauma, including serious cardiothoracic injuries. Supplementary data to this article can be found online at http:// dx.doi.org/10.1016/j.ijcard.2014.01.010. References [1] Symbas PJ, Horsley WS, Symbas PN. Rupture of the ascending aorta caused by blunt trauma. Ann Thorac Surg 1998;66:113–7. [2] Christensen MD, Nielsen PE, Sleight P. Prior blunt chest trauma may be a cause of single vessel coronary disease; hypothesis and review. Int J Cardiol Mar 22 2006;108(1):1–5. [3] Fu M, Wu CJ, Hsieh MJ. Coronary dissection and myocardial infarction following blunt chest trauma. J Formos Med Assoc 1999;98:136–40. [4] Moreno R, del Todo JP, Nieto M, et al. Primary stenting in acute myocardial infarction secondary to right coronary artery dissection following blunt chest trauma. Usefulness of intracoronary ultrasound. Int J Cardiol 2005;103:209–11.
Fig. 3. Thoracoabdominal computed tomographic (CT) angiography showed the localized dissection flap in the ascending aorta.
0167-5273/$ – see front matter © 2014 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2014.01.010
119
Contents lists available at ScienceDirect
International Journal of Cardiology j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j c a r d
Letters to the Editor
Airbag inflation-related left main coronary artery dissection, localized aortic dissection and aortic valve dehiscence in a patient with previous coronary artery surgery☆ Fatih Mehmet Uçar ⁎, Fatih Şen, Murat Karamanlioğli, Kumral Çağli Turkey Yuksek Ihtisas Education and Research Hospital, Ankara, Turkey
a r t i c l e
i n f o
Article history: Received 13 October 2013 Received in revised form 30 December 2013 Accepted 1 January 2014 Available online 1 February 2014 Keywords: Airbag Dissection Dehiscence
Almost 30% of all trauma patients have some form of cardiothoracic injury [1]. The diagnosis of blunt cardiac injury can be challenging because chemical markers, nuclear studies and echocardiograms rarely correlate with the severity of injury. Combination of coronary artery injury, aortic dissection and acute aortic valve rupture after blunt chest trauma is very rare but can be rapidly fatal and requires prompt recognition and treatment. In this report we describe a case of a male patient who had an airbag inflated car crash that resulted in a left main coronary artery (LMCA) dissection, localized aortic dissection and dehiscence of aortic valve commissure. A 60 year-old male patient with a 2-day history of car crash was transferred to our hospital for evaluation of refractory chest pain. The patient has been the driver of the car and hit a wall after losing the control of the car due to going too fast. The crash has resulted in the inflation of the front driver's airbag that was followed by a sudden retrosternal chest pain without any penetrating injury. He was admitted to a local hospital first but since he had refractory chest pain and troponin positivity, he was transferred to our hospital. His past medical history was remarkable for coronary artery bypass surgery (left internal mammary artery (LIMA) to left anterior descending artery (LAD)) that was performed 7 years ago. On admission, his blood pressure was 120/75 mm Hg, heart rate was 95 beats per minute, and respiration rate was 20 per minute. Carotid and
☆ This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-No Derivative Works License, which permits non-commercial use, distribution, and reproduction in any medium, provided the original author and source are credited. PII of original article: . ⁎ Corresponding author. Tel.: +90 5543459797.
jugular venous pulsations were normal. Palpation of the anterior chest wall, especially the sternal area was painful but auscultation of the lungs was normal. The first and second heart sounds were normal with a 2/6 diastolic murmur along the right sternal border. There were no signs and symptoms of abdominal injury and fractures of extremity. Surface electrocardiogram revealed sinus rhythm and STsegment depression and T-wave inversion in leads V3–V6. Chest X-ray showed uncomplicated fractures of ribs and sternum with a normal cardiothoracic ratio. His cardiac biomarkers were found to be elevated (creatinine phosphokinase-MB: 135 ng/mL (b3 ng/mL) and troponin: 2.1 ng/mL (b0.04)). Transthoracic echocardiography showed mild to moderate aortic regurgitation and a reduced left ventricular ejection fraction (EF 40%) with akinesia of apical segments. He underwent selective coronary angiography which revealed a Type A dissection of the LMCA that extended to the proximal LAD (Fig. 1, Video-1) with a patent LIMA–LAD bypass and TIMI 3 distal flow. His aortogram demonstrated a short dissection flap in the ascending aorta just above the aortic valve (Fig. 2, Video-2). Transesophageal echocardiography (TEE) revealed dehiscence of the non-coronary cusp of the aortic valve that resulted in a mildlymoderate aortic regurgitation and a 9 mm sized intimal flap in the ascending aorta just above the non-coronary cusp (Video-3).
Fig. 1. Dissection of the left main coronary artery image demonstrated by angiogram.
Letters to the Editor
Fig. 2. Localized aortic dissection of the ascending aorta image demonstrated by angiogram.
Thoracoabdominal computed tomographic angiography confirmed the diagnosis of traumatic aortic dissection in the ascending aorta without any extension beyond the sinotubular junction (Fig. 3). Blunt chest trauma may result in various cardiovascular injuries. The most common injury after blunt chest trauma is myocardial contusion. Coronary artery dissection is a rare condition which accounts for 15.8% of myocardial infarction due to blunt chest trauma [2]. Dissection most often occurs in the left anterior descending artery [3], followed by the right coronary artery [4]. Although rare, left main coronary artery involvement has also been reported. Mechanisms of acute myocardial infarction following traumainduced coronary artery dissection are unclear, but shearing forces during the traumatic episode may produce a small intimal tear which subsequently initiates the process of thrombus formation. Thrombolytic therapy for the acute phase of these patients is controversial because it
may worsen the dissection itself. Treatment of coronary artery dissection patients, conservative management, percutaneous interventions or CABG are recommended. Aortic valve dehiscence with localized aortic dissection resulting in acute aortic insufficiency is an uncommon complication of blunt chest trauma. Sudden increase in intrathoracic pressure is the mechanism of dissection and dehiscence. Nearly all authors recommend that surgical intervention be done as soon as possible in such cases. In our patient, we decided to proceed to surgery. Laceration of an aortic valve cusp and aortic dissection were treated successfully with urgent surgery. Surgeons removed as much of the dissected aorta as possible, blocked the entry of blood into the aortic wall and reconstructed the aorta with a synthetic tube called a graft than the valve is placed within the graft that is used to reconstruct the aorta. LMCA dissection was treated conservatively and discharged without serious sequelae. The automotive safety systems are playing an important role in saving lives during crashes. One such device is the airbag which has become a standard equipment in all automobiles and is generally assumed to improve driver and passenger safety in the event of a crash. Although the airbag affords valuable protection against crushing injuries of the head and body, it can cause other, less apparent, blunt trauma, including serious cardiothoracic injuries. Supplementary data to this article can be found online at http:// dx.doi.org/10.1016/j.ijcard.2014.01.010. References [1] Symbas PJ, Horsley WS, Symbas PN. Rupture of the ascending aorta caused by blunt trauma. Ann Thorac Surg 1998;66:113–7. [2] Christensen MD, Nielsen PE, Sleight P. Prior blunt chest trauma may be a cause of single vessel coronary disease; hypothesis and review. Int J Cardiol Mar 22 2006;108(1):1–5. [3] Fu M, Wu CJ, Hsieh MJ. Coronary dissection and myocardial infarction following blunt chest trauma. J Formos Med Assoc 1999;98:136–40. [4] Moreno R, del Todo JP, Nieto M, et al. Primary stenting in acute myocardial infarction secondary to right coronary artery dissection following blunt chest trauma. Usefulness of intracoronary ultrasound. Int J Cardiol 2005;103:209–11.
Fig. 3. Thoracoabdominal computed tomographic (CT) angiography showed the localized dissection flap in the ascending aorta.
0167-5273/$ – see front matter © 2014 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2014.01.010
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