Images in Cardiovascular Medicine Aortic Dissection Manifesting as ST-Segment–Elevation Myocardial Infarction Alexander Chen, MD; Xiushui Ren, MD

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n 80-year-old man presented to the emergency department with acute chest discomfort. An ECG showed sinus rhythm with 1-mm ST-segment elevation in the inferior limb leads. He was brought to the cardiac catheterization laboratory for primary percutaneous coronary intervention. Selective angiography of the left coronary system showed no obstructive disease. The initial attempt to selectively engage the right coronary artery (RCA) was unsuccessful, and contrast injection through the JR-4 catheter showed aortic regurgitation (Figure 1 and Movie I in the online-only Data Supplement). After repositioning of the JR-4 catheter, angiography showed a patent RCA without aortic regurgitation, suggesting that the RCA ostium originates from the false lumen of a type A aortic dissection (Figure 2 and Movie II in the online-only Data Supplement). This diagnosis was confirmed with aortography, demonstrating severe aortic regurgitation likely caused by a dissection flap interfering with aortic valve function (Figure 3 and Movie III in the online-only Data Supplement). Acute type A aortic dissection can be challenging to diagnose. Abrupt-onset chest pain occurs in ≈80% of patients and is frequently sharp and severe in quality.1 Although an ECG commonly shows nonspecific ST-segment or T-wave changes, signs of acute myocardial infarction occur in only 5% of patients.1 When dissection is complicated by acute myocardial infarction, the mechanism may be extension of dissection into a coronary artery or ostial coronary occlusion from the dissection flap, often

affecting the RCA.2,3 The higher incidence of RCA involvement is attributed to dissection originating more commonly from the right anterior aspect of the ascending aorta above the right sinus of Valsalva. In the current era of primary percutaneous coronary intervention with emphasis on door-to-balloon time, aortic dissection should be part of the differential diagnosis of ST-segment–elevation myocardial infarction. Difficulty with catheter engagement or significant aortic regurgitation should raise the suspicion for acute type A aortic dissection.

Disclosures None.

References 1. Hagan PG, Nienaber CA, Isselbacher EM, Bruckman D, Karavite DJ, Russman PL, Evangelista A, Fattori R, Suzuki T, Oh JK, Moore AG, Malouf JF, Pape LA, Gaca C, Sechtem U, Lenferink S, Deutsch HJ, Diedrichs H, Marcos y Robles J, Llovet A, Gilon D, Das SK, Armstrong WF, Deeb GM, Eagle KA. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000;283:897–903. 2. Spittell PC, Spittell JA Jr, Joyce JW, Tajik AJ, Edwards WD, Schaff HV, Stanson AW. Clinical features and differential diagnosis of aortic dissection: experience with 236 cases (1980 through 1990). Mayo Clin Proc. 1993;68:642–651. 3. Imoto K, Uchida K, Karube N, Yasutsune T, Cho T, Kimura K, Masuda M, Morita S. Risk analysis and improvement of strategies in patients who have acute type A aortic dissection with coronary artery dissection. Eur J Cardiothorac Surg. 2013;44:419–424. doi: 10.1093/ejcts/ezt060.

From Kaiser Permanente Medical Center, Redwood City, CA. The online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA. 114.015200/-/DC1. Correspondence to Xiushui Ren, MD, Kaiser Permanente Medical Center, 1190 Veterans Blvd, Redwood City, CA 94063. E-mail [email protected] (Circulation. 2015;131:e503-e504. DOI: 10.1161/CIRCULATIONAHA.114.015200.) © 2015 American Heart Association, Inc. Circulation is available at http://circ.ahajournals.org

DOI: 10.1161/CIRCULATIONAHA.114.015200

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e504  Circulation  May 26, 2015

Figure 1. Contrast injection with a JR-4 catheter in the left anterior oblique view showing a lack of right coronary artery ostium and dissection flap (arrows) and aortic regurgitation.

Figure 3. Aortography in the left anterior oblique view showing the true lumen delineated by the dissection flap (arrows), severe aortic regurgitation, and no evidence of the right coronary artery ostium.

Figure 2. Selective angiography of the right coronary artery with a JR-4 catheter in the left anterior oblique view showing a patent artery and no aortic regurgitation, demonstrating that the right coronary artery ostium originates from the false lumen of a type A aortic dissection.

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Aortic Dissection Manifesting as ST-Segment−Elevation Myocardial Infarction Alexander Chen and Xiushui Ren Circulation. 2015;131:e503-e504 doi: 10.1161/CIRCULATIONAHA.114.015200 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/131/21/e503

Data Supplement (unedited) at: http://circ.ahajournals.org/content/suppl/2015/05/26/CIRCULATIONAHA.114.015200.DC1.html

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