Cardiovasc Interv and Ther DOI 10.1007/s12928-014-0250-z
CASE REPORT
Percutaneous coronary intervention is a useful bridge treatment for acute myocardial infarction due to acute type A aortic dissection Satoshi Kodera • Masayuki Ikeda • Kazutoshi Sato Syunichi Kushida • Junji Kanda
•
Received: 11 March 2013 / Accepted: 31 January 2014 Ó Japanese Association of Cardiovascular Intervention and Therapeutics 2014
Abstract We report a 71-year-old woman with inferior acute myocardial infarction (AMI) due to type A acute aortic dissection. Emergency enhanced computed tomography (CT) did not show obvious aortic dissection. During emergency percutaneous coronary intervention (PCI), intravascular ultrasonography revealed type A aortic dissection. Hemodynamic stability was restored after PCI. 1 month later, CT revealed a sinus of Valsalva aneurysm, which was treated surgically. This case suggests that PCI could be a good initial treatment option for unstable patients with AMI due to type A aortic dissection. This is the first reported case of sinus of Valsalva aneurysm subsequent to aortic dissection.
emergency surgery [4]. However, diagnosis is difficult in some cases [5], and the surgery may be difficult to perform. Some patients are so unstable that they cannot wait for surgery; for these patients percutaneous coronary intervention (PCI) is useful. There are several reports of patients with AMI due to type A aortic dissection who were successfully treated with PCI [6–15]. We report a case of AMI due to type A aortic dissection that was successfully treated with PCI in an emergency situation. The patient underwent surgery 1 month later for a sinus of Valsalva aneurysm.
Keywords Percutaneous coronary intervention Aneurysm Inferior acute myocardial infarction Acute aortic dissection
Our patient was a 71-year-old woman with a history of type A acute aortic dissection in 2006. That dissection had extended from the root of the aorta to the celiac artery and was of thrombosed type with a small ulcer-like projection of the ascending aorta 2.5 cm distal to the right coronary artery (RCA) ostium. There had been some pericardial effusion and aortic regurgitation but no tamponade nor coronary involvement. She had been treated medically because she was hemodynamically stable, with no evidence of malperfusion and no residual false lumen. In 2010, echocardiography showed mild dilation of the ascending aorta (45 mm) and moderate aortic regurgitation. She was asymptomatic until the morning of admission in May 2011, when she attended our hospital for a periodic medical checkup for hypertension. When she was waiting in the outpatient clinic, she complained of sudden chest discomfort and gradually lost consciousness. She was immediately transferred to the emergency department. On arrival there, her systolic blood pressure was 70 mmHg, her heart rate 30 beats/min, and she had regained consciousness. Examination revealed a grade III/VI diastolic heart murmur in the second intercostal space
Introduction Type A aortic dissection is associated with a 7–13 % incidence of retrograde dissection of one or both coronary ostia [1, 2]. Dissection of the coronary ostia causes acute myocardial infarction (AMI). As the mortality rate of patients with AMI with type A aortic dissection is high, treatment is challenging [3]. The standard treatment is S. Kodera (&) K. Sato S. Kushida J. Kanda Department of Cardiovascular Medicine, Asahi General Hospital, I-1326 Asahi, Chiba 289-2511, Japan e-mail: [email protected] M. Ikeda Graduate School of Biomedical Sciences, Nagasaki University, 1-14 Bunkyo-machi, Nagasaki 852-8521, Japan
Case report
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Fig. 1 A-1, A-2, A-3 Enhanced CT images at the time of admission. A-2 White arrow shows thrombosed type of dissection at the ostium of RCA. A-3 Longitudinal view of Valsalva with curved planar reconstruction. White arrow show thrombosed type of dissection at the ostium of RCA. B-1, B-2, B-3 Electrocardiogram-gated CT images on day 2. B-2 White arrow shows limited dissection and entry
site of the dissection. There is no pericardial effusion. B-3 Longitudinal view of sinus of Valsalva with curved planar reconstruction. White arrow shows limited dissection with some leakage of contrast. Ao aorta, SVC superior vena cava, PA pulmonary artery, RA right atrium, RV right ventricle, LA left atrium, RCC right coronary cusp, LCC left coronary cusp, LV left ventricle
at the sternal border that had previously been detected. The remainder of the examination was normal. Laboratory data were unremarkable. Electrocardiography revealed 2:1 heart block and ST elevation in leads II, III, and aVF. Transthoracic echocardiography revealed decreased motion of the inferior part of the left ventricle. She was diagnosed as having an inferior AMI. Because of her history, we suspected that her AMI had been caused by type A aortic dissection. However, enhanced computed tomography (CT) did not reveal an aortic dissection (Fig. 1). We administered aspirin, clopidogrel, and heparin and performed emergency PCI. We handled the catheter carefully so as not to injure the aorta. Coronary angiography revealed a severely narrowed proximal RCA (Fig. 2a) with Thrombolysis In Myocardial Infarction (TIMI) grade 2 flow. We performed emergency revascularization using a 6 French Judkins right 4.0 guiding catheter. We tried to remove thrombus via a 6-French
aspiration catheter (Thrombuster II, Kaneka, Osaka, Japan), but were unable to aspirate any material. Suspecting dissection of the RCA, we performed intravascular ultrasonography (IVUS), which revealed circumferential dissection extending from the aortic wall to the mid-portion of the RCA (Fig. 3). The true lumen was severely compressed by a large false lumen. We could not detect the entry site with IVUS, the findings of which suggested AMI secondary to RCA compression due to type A aortic dissection. To stabilize the patient’s blood pressure and heart rate, we placed a 4 9 15 mm bare metal stent (Driver, Medtronic Inc., MN, USA) at the ostium of the RCA. Because the RCA was still narrowed after deployment of this stent (Fig. 2b), we placed a 3.5 mm 9 18 mm bare metal stent (Liberte stent, Boston Scientific Co., MA, USA) distal to the first stent. Flow in the RCA was still unsatisfactory (Fig. 2c), so we placed another 3.5 mm 9 30 mm DriverTM stent distal to the second stent.
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PCI for AMI due to type A aortic dissection Fig. 2 a Angiography of the RCA before PCI, showing severe stenosis. b Residual stenosis after deployment of the first stent. c Stenosis of the midportion of the RCA after deployment of the second stent. d No stenosis after deployment of the third stent
This resolved the narrowing of the RCA (Fig. 2d) and the patient’s blood pressure and heart rate returned to normal. IVUS showed open stents and a residual false lumen originating from the ostium of the RCA and extending to the proximal part of the RCA. Because the entry site of the dissection was located in the aorta, we could not close it with a stent. We confirmed TIMI grade 3 flow in the RCA before finishing the procedure and transferring the patient to the cardiac care unit. Even though we could detect no pericardial effusion, we were concerned about possible expansion of the dissection toward the left main artery or cardiac tamponade and therefore consulted a cardiac surgeon regarding emergency surgery, who considered that medical treatment was sufficient because of her limited aortic dissection and stable condition. Aspirin and clopidogrel treatment were continued to prevent stent thrombosis. The next day, electrocardiogram-gated CT showed only limited dissection of the aorta, some enlargement of the right sinus of Valsalva and no pericardial or pleural effusions (Fig. 1). The radiologist reviewed the patient’s admission CT and identified a thrombosed type of dissection (Fig. 1). We again considered
emergency surgery, but because 24 h had already passed since the onset of symptoms and the patient was pain free and hemodynamically stable without evidence of malperfusion, we decided to manage her with strict control of blood pressure to prevent progression of her aortic dissection. The use of antiplatelet drugs was also considered a relative contraindication for surgery. We followed the patient carefully. On day 3, the Great East Japan Earthquake occurred, making it difficult to perform surgery because of power failure and aftershocks. Follow-up CT on days 7 and 14 after PCI showed some enlargement of the aneurysm of Valsalva. Further follow-up CT on day 26 after PCI revealed a giant aneurysm of the right sinus of Valsalva (Fig. 4). Although the dissection was limited to the right sinus of Valsalva, the aneurysm was 2 cm in diameter and growing rapidly. We therefore decided to perform surgery to prevent its rupture. The patient underwent RCA bypass surgery and replacement of the ascending aorta and aortic valve. The surgeons detected dissection around the RCA and a thumb-sized aneurysm at the ostium of the RCA (Fig. 5). There was an entry site around the RCA and they found the stents in the
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Fig. 3 IVUS images showing extensive dissection from the ostium to the mid-portion of the RCA. The white arrows show the intima
ostium of the RCA. They performed a Bentall procedure with composite graft including vascular graft (Triplex 26 mm, Terumo Corporation, Tokyo, Japan) and aortic valve (Mosaic ultra 23 mm, Medtronic Inc., MN, USA) and reconstructed the left coronary with a Carrel patch. Because it was difficult to reconstruct the RCA with a Carrel patch, they performed bypass surgery for the RCA using a saphenous vein graft. Ten hours after the surgery, the patient’s blood pressure and heart rate dropped dramatically and she required cardiopulmonary resuscitation. The surgeons reopened her chest and detected a hematoma, but no active bleeding, around the distal anastomosis of the ascending aorta. They inserted an additional drainage tube around the ascending aorta. After reoperation, the patient’s vital signs recovered temporarily. Continuous hemodialysis was performed because of oliguria. On the following day, the blood pressure dropped gradually even though they were being administered high-dose catecholamines. The patient died 2 days after surgery.
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Discussion Even though the standard treatment for this condition is surgery [4], we did not use surgery to treat a patient with AMI due to type A aortic dissection in an emergency situation. There were two reasons for our decision not to perform emergency surgery. First, we were unable to diagnose AMI due to type A aortic dissection in the emergency department, even though we suspected this diagnosis and therefore performed emergency CT. However, her dissection was too limited to be identified by this procedure. Because the presentation of AMI with type A aortic dissection is similar to that of AMI without aortic dissection, the diagnosis of dissection is difficult in an emergency situation [5]. Japan AMI registry showed median door-to-balloon time was 42 min in emergency situation [16]. Second, the guidelines for treatment of aortic dissection are not based on good evidence. No randomized studies of medical versus surgical management for AMI due to aortic dissection have been performed. The
PCI for AMI due to type A aortic dissection Fig. 4 a, b CT images showing a giant aneurysm of the right sinus of Valsalva 1 month after stent placement. The white arrows show the aneurysm. c Short axis view of sinus of Valsalva. White arrows show the aneurysm. There is an entry point at RCC. d Long axis view of Valsalva. White arrows show the aneurysm. There is an entry point at the RCC. RCC right coronary cusp, LCC left coronary cusp, NCC non coronary cusp
guidelines recommending surgery for aortic dissection are based on reports of case series [17]. Some data show that medical management is better than surgical management in cases of thrombosed type A aortic dissection [18]. We thought that the patient’s condition suggested a thrombosed aortic dissection, and therefore treated her by PCI instead of surgery. To evaluate the usefulness of PCI in such cases, we have reviewed previous case reports of patients with AMI due to type A aortic dissection who were treated with PCI [6–15]. Table 1 shows all the reported cases. Most of these patients were in shock at the time of admission. Urgent diagnosis and treatment are essential; however, 50 % of cases were diagnosed after PCI. These data suggest that the diagnosis of AMI due to type A aortic dissection is difficult. Most of the cases were diagnosed by CT and several by transesophageal echocardiography. Among these patients, left main coronary artery lesions were more common than RCA lesions, even though type A aortic dissection usually involves the RCA. Because left main coronary artery lesions are much more severe than RCA lesions, they require emergency PCI. Most of the reported cases underwent surgery for the aortic dissection soon after PCI, and survived. Ikari [19] reported successful treatment with PCI for AMI after surgery of acute aortic dissection.
Clearly, PCI in patients with AMI caused by aortic dissection is potentially dangerous because it could exacerbate the dissection. In addition, PCI could delay surgical interventions. These case reports suggest that PCI is a good presurgical treatment option for critically ill patients with AMI due to type A aortic dissection. It is important to question why our patient developed an aneurysm. She had a history of type A aortic dissection, which had been treated medically. The entry site of the previous dissection was located 2.5 cm distal from the RCA. The previous aortic dissection had led to weakness of the tunica media between the aorta and the annulus fibrosis of the aortic valve [20]. This weakness of the aortic wall led to dilation of the sinus of Valsalva, which predisposed her to aortic dissection at this site. Dissection of the sinus of Valsalva extended to the inner layer of the RCA, leading to RCA occlusion. Thrombosed dissection was present before the PCI. We believed it might be possible to reopen the entry site with a catheter. Akutagawa [21] reported acute coronary occlusion by injured aortic valve with a catheter. We placed stents to restore RCA perfusion, but could not close the entry site of the aortic dissection with stents. Continued flow into the entry site therefore led to formation of the aneurysm. We used heparin and aspirin to prevent stent thrombosis; however, this antiplatelet therapy
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S. Kodera et al. Fig. 5 Bypass surgery and replacement of ascending aorta and aortic valve. Aneurysm at ostium of RCA. b Replacement of aortic valve and RCA bypass. c There is an aneurysm at the ostium of the RCA. d Entry site around the RCA
Table 1 Characteristics of reported cases who underwent stent placement for AMI due to type A aortic dissection Age, sex
Shock
Diagnosis before/after PCI
Diagnostic modality
Location of lesion
Number of stents
Operation
Outcome
74 M
-
After
TEE
LM
1
?
Alive
67 M
?
After
CT
LM
1
-
Dead
68 M
?
After
TEE
LM
1
-
Dead
41 M
?
After
CT
LM
2
?
Alive
71 M
?
Before
CT
RCA
1
?
Alive
69 M
?
After
IVUS
RCA
NA
?
NA
49 F
-
After
TEE
RCA
NA
?
Alive
62 M
?
Before
CT
RCA
2
?
Alive
67 F
-
After
CT
RCA
NA
?
Alive
57 M
?
Before
CT
LM
1
?
Alive
52 M
?
After
TEE
LM
1
?
Alive
AMI acute myocardial infarction, PCI percutaneous coronary intervention, TEE transesophageal echocardiography, LM left main coronary artery, CT computed tomography, IVUS intravascular ultrasonography, RCA right coronary artery, IVUS intravascular ultrasonography, NA not available
likely prevented closure of the entry site. The false lumen enlarged, forming an aneurysm of the sinus of Valsalva. We believe that PCI could be a good initial treatment option for critically ill patients with AMI due to type A aortic dissection. This is the first reported case of aneurysm formation after PCI for AMI with aortic dissection.
References 1. Neri E, Toscano T, Papalia U, Frati G, Massetti M, Capannini G, et al. Proximal aortic dissection with coronary malperfusion: presentation, management, and outcome. J Thorac Cardiovasc Surg. 2001;121:552–60.
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2. Me´sza´ros I, Mo´rocz J, Szla´vi J, Schmidt J, Torno´ci L, Nagy L, et al. Epidemiology and clinicopathology of aortic dissection. Chest. 2000;117:1271–8. 3. Hirst AE Jr, Johns VJ Jr, Kime SW Jr. Dissecting aneurysm of the aorta: a review of 505 cases. Medicine (Baltimore). 1958;37: 217–79. 4. Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE Jr, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/ SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation. 2010;121:e266–369.
PCI for AMI due to type A aortic dissection 5. Spittell PC, Spittell JA Jr, Joyce JW, Tajik AJ, Edwards WD, Schaff HV, et al. Clinical features and differential diagnosis of aortic dissection: experience with 236 cases (1980 through 1990). Mayo Clin Proc. 1993;68:642–51. 6. Barabas M, Gosselin G, Crepeau J, Petitclerc R, Cartier R, Theroux P. Left main stenting—as a bridge to surgery—for acute type A aortic dissection and anterior myocardial infarction. Catheter Cardiovasc Interv. 2000;51:74–7. 7. Ohara Y, Hiasa Y, Hosokawa S. Successful treatment in a case of acute aortic dissection complicated with acute myocardial infarction due to occlusion of the left main coronary artery. J Invasive Cardiol. 2003;15:660–2. 8. Cardozo C, Riadh R, Mazen M. Acute myocardial infarction due to left main compression aortic dissection treated by direct stenting. J Invasive Cardiol. 2004;16:89–91. 9. Kwon YS, Lee HS, Shin JK, Chang BJ, Kim HS, Shin SC, et al. A case of left main coronary stenting for acute myocardial infarction complicated by ascending aortic dissection. Korean Circ J. 2004;34:1210–5. 10. Imoto K, Uchida K, Suzuki S, Isoda S, Karube N, Kimura K. Stenting of a left main coronary artery dissection and stent-graft implantation for acute type a aortic dissection. J Endovasc Ther. 2005;12:258–61. 11. Na SH, Youn TJ, Cho YS, Lim C, Chung WY, Chae IH, et al. Acute myocardial infarction caused by extension of a proximal aortic dissection flap into the right coronary artery. Circulation. 2006;113:e669–71. 12. Ohnaka M, Nakayama S, Nonaka M, Inashima M. A successfully treated case of acute type A aortic dissection with right coronary dissection. Jpn J Vasc Surg. 2007;16:583–7 [in Japanese].
13. Hatakeyama M, Takahara Y, Mogi K, Kabasawa M. Acute type A aortic dissection with acute left main coronary trunk occlusion: a case report of left main stenting as a bridge surgery. Jpn J Cardiovasc Surg. 2008;37:353–7 [in Japanese]. 14. Camaro C, Wouters NT, Gin MT, Bosker HA. Acute myocardial infarction with cardiogenic shock in a patient with acute aortic dissection. Am J Emerg Med. 2009;27(899):e3–6. 15. Sir JJ, Kim YI, Cho WH, Choi SK. Acute myocardial infarction due to aortic dissection. Intern Med. 2009;48:173. 16. Nakamura M, Yamagishi M, Ueno T, Hara K, Ishiwata S, Itho T, et al. Current treatment of ST elevation acute myocardial infarction in Japan: door-to-balloon time and total ischemic time from the J-AMI registry. Cardiovasc Interv Ther. 2013;28:30–6. 17. Bonser RS, Ranasinghe AM, Loubani M, Evans JD, Thalji NMA, Bachet JE, et al. Evidence, lack of evidence, controversy, and debate in the provision and performance of the surgery of acute type A aortic dissection. J Am Coll Cardiol. 2011;58:2455–74. 18. Kaji S, Akasaka T, Horibata Y, Nishigami K, Shono H, Katayama M, et al. Long-term prognosis of patients with type A aortic intramural hematoma. Circulation. 2002;106:I248–52. 19. Ikari Y, Hara K, Tamura T, Hara H, Saeki F, Kikawa I, et al. Intracoronary stenting of a coronary occlusion resulting from an aortic dissection. Cather Cardiovasc Diagn. 1995;36:160–3. 20. Origuchi N, Ohkawa S, Esaki Y, Yoshida Y, Shigematsu H. Rare complication of saccular aneurysm and histological dissection: an autopsy study of 5865 elderly cases. Jpn Heart J. 2001;42:597–606. 21. Akutagawa O, Kijima Y, Nakagawa Y, Hata T, Ishizaka T, Takahashi T. Acute coronary occlusion by injured aortic valve during percutaneous coronary intervention. Cardiovasc Interv Ther. 2012;27:43–6.
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CASE REPORT
Percutaneous coronary intervention is a useful bridge treatment for acute myocardial infarction due to acute type A aortic dissection Satoshi Kodera • Masayuki Ikeda • Kazutoshi Sato Syunichi Kushida • Junji Kanda
•
Received: 11 March 2013 / Accepted: 31 January 2014 Ó Japanese Association of Cardiovascular Intervention and Therapeutics 2014
Abstract We report a 71-year-old woman with inferior acute myocardial infarction (AMI) due to type A acute aortic dissection. Emergency enhanced computed tomography (CT) did not show obvious aortic dissection. During emergency percutaneous coronary intervention (PCI), intravascular ultrasonography revealed type A aortic dissection. Hemodynamic stability was restored after PCI. 1 month later, CT revealed a sinus of Valsalva aneurysm, which was treated surgically. This case suggests that PCI could be a good initial treatment option for unstable patients with AMI due to type A aortic dissection. This is the first reported case of sinus of Valsalva aneurysm subsequent to aortic dissection.
emergency surgery [4]. However, diagnosis is difficult in some cases [5], and the surgery may be difficult to perform. Some patients are so unstable that they cannot wait for surgery; for these patients percutaneous coronary intervention (PCI) is useful. There are several reports of patients with AMI due to type A aortic dissection who were successfully treated with PCI [6–15]. We report a case of AMI due to type A aortic dissection that was successfully treated with PCI in an emergency situation. The patient underwent surgery 1 month later for a sinus of Valsalva aneurysm.
Keywords Percutaneous coronary intervention Aneurysm Inferior acute myocardial infarction Acute aortic dissection
Our patient was a 71-year-old woman with a history of type A acute aortic dissection in 2006. That dissection had extended from the root of the aorta to the celiac artery and was of thrombosed type with a small ulcer-like projection of the ascending aorta 2.5 cm distal to the right coronary artery (RCA) ostium. There had been some pericardial effusion and aortic regurgitation but no tamponade nor coronary involvement. She had been treated medically because she was hemodynamically stable, with no evidence of malperfusion and no residual false lumen. In 2010, echocardiography showed mild dilation of the ascending aorta (45 mm) and moderate aortic regurgitation. She was asymptomatic until the morning of admission in May 2011, when she attended our hospital for a periodic medical checkup for hypertension. When she was waiting in the outpatient clinic, she complained of sudden chest discomfort and gradually lost consciousness. She was immediately transferred to the emergency department. On arrival there, her systolic blood pressure was 70 mmHg, her heart rate 30 beats/min, and she had regained consciousness. Examination revealed a grade III/VI diastolic heart murmur in the second intercostal space
Introduction Type A aortic dissection is associated with a 7–13 % incidence of retrograde dissection of one or both coronary ostia [1, 2]. Dissection of the coronary ostia causes acute myocardial infarction (AMI). As the mortality rate of patients with AMI with type A aortic dissection is high, treatment is challenging [3]. The standard treatment is S. Kodera (&) K. Sato S. Kushida J. Kanda Department of Cardiovascular Medicine, Asahi General Hospital, I-1326 Asahi, Chiba 289-2511, Japan e-mail: [email protected] M. Ikeda Graduate School of Biomedical Sciences, Nagasaki University, 1-14 Bunkyo-machi, Nagasaki 852-8521, Japan
Case report
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Fig. 1 A-1, A-2, A-3 Enhanced CT images at the time of admission. A-2 White arrow shows thrombosed type of dissection at the ostium of RCA. A-3 Longitudinal view of Valsalva with curved planar reconstruction. White arrow show thrombosed type of dissection at the ostium of RCA. B-1, B-2, B-3 Electrocardiogram-gated CT images on day 2. B-2 White arrow shows limited dissection and entry
site of the dissection. There is no pericardial effusion. B-3 Longitudinal view of sinus of Valsalva with curved planar reconstruction. White arrow shows limited dissection with some leakage of contrast. Ao aorta, SVC superior vena cava, PA pulmonary artery, RA right atrium, RV right ventricle, LA left atrium, RCC right coronary cusp, LCC left coronary cusp, LV left ventricle
at the sternal border that had previously been detected. The remainder of the examination was normal. Laboratory data were unremarkable. Electrocardiography revealed 2:1 heart block and ST elevation in leads II, III, and aVF. Transthoracic echocardiography revealed decreased motion of the inferior part of the left ventricle. She was diagnosed as having an inferior AMI. Because of her history, we suspected that her AMI had been caused by type A aortic dissection. However, enhanced computed tomography (CT) did not reveal an aortic dissection (Fig. 1). We administered aspirin, clopidogrel, and heparin and performed emergency PCI. We handled the catheter carefully so as not to injure the aorta. Coronary angiography revealed a severely narrowed proximal RCA (Fig. 2a) with Thrombolysis In Myocardial Infarction (TIMI) grade 2 flow. We performed emergency revascularization using a 6 French Judkins right 4.0 guiding catheter. We tried to remove thrombus via a 6-French
aspiration catheter (Thrombuster II, Kaneka, Osaka, Japan), but were unable to aspirate any material. Suspecting dissection of the RCA, we performed intravascular ultrasonography (IVUS), which revealed circumferential dissection extending from the aortic wall to the mid-portion of the RCA (Fig. 3). The true lumen was severely compressed by a large false lumen. We could not detect the entry site with IVUS, the findings of which suggested AMI secondary to RCA compression due to type A aortic dissection. To stabilize the patient’s blood pressure and heart rate, we placed a 4 9 15 mm bare metal stent (Driver, Medtronic Inc., MN, USA) at the ostium of the RCA. Because the RCA was still narrowed after deployment of this stent (Fig. 2b), we placed a 3.5 mm 9 18 mm bare metal stent (Liberte stent, Boston Scientific Co., MA, USA) distal to the first stent. Flow in the RCA was still unsatisfactory (Fig. 2c), so we placed another 3.5 mm 9 30 mm DriverTM stent distal to the second stent.
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PCI for AMI due to type A aortic dissection Fig. 2 a Angiography of the RCA before PCI, showing severe stenosis. b Residual stenosis after deployment of the first stent. c Stenosis of the midportion of the RCA after deployment of the second stent. d No stenosis after deployment of the third stent
This resolved the narrowing of the RCA (Fig. 2d) and the patient’s blood pressure and heart rate returned to normal. IVUS showed open stents and a residual false lumen originating from the ostium of the RCA and extending to the proximal part of the RCA. Because the entry site of the dissection was located in the aorta, we could not close it with a stent. We confirmed TIMI grade 3 flow in the RCA before finishing the procedure and transferring the patient to the cardiac care unit. Even though we could detect no pericardial effusion, we were concerned about possible expansion of the dissection toward the left main artery or cardiac tamponade and therefore consulted a cardiac surgeon regarding emergency surgery, who considered that medical treatment was sufficient because of her limited aortic dissection and stable condition. Aspirin and clopidogrel treatment were continued to prevent stent thrombosis. The next day, electrocardiogram-gated CT showed only limited dissection of the aorta, some enlargement of the right sinus of Valsalva and no pericardial or pleural effusions (Fig. 1). The radiologist reviewed the patient’s admission CT and identified a thrombosed type of dissection (Fig. 1). We again considered
emergency surgery, but because 24 h had already passed since the onset of symptoms and the patient was pain free and hemodynamically stable without evidence of malperfusion, we decided to manage her with strict control of blood pressure to prevent progression of her aortic dissection. The use of antiplatelet drugs was also considered a relative contraindication for surgery. We followed the patient carefully. On day 3, the Great East Japan Earthquake occurred, making it difficult to perform surgery because of power failure and aftershocks. Follow-up CT on days 7 and 14 after PCI showed some enlargement of the aneurysm of Valsalva. Further follow-up CT on day 26 after PCI revealed a giant aneurysm of the right sinus of Valsalva (Fig. 4). Although the dissection was limited to the right sinus of Valsalva, the aneurysm was 2 cm in diameter and growing rapidly. We therefore decided to perform surgery to prevent its rupture. The patient underwent RCA bypass surgery and replacement of the ascending aorta and aortic valve. The surgeons detected dissection around the RCA and a thumb-sized aneurysm at the ostium of the RCA (Fig. 5). There was an entry site around the RCA and they found the stents in the
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Fig. 3 IVUS images showing extensive dissection from the ostium to the mid-portion of the RCA. The white arrows show the intima
ostium of the RCA. They performed a Bentall procedure with composite graft including vascular graft (Triplex 26 mm, Terumo Corporation, Tokyo, Japan) and aortic valve (Mosaic ultra 23 mm, Medtronic Inc., MN, USA) and reconstructed the left coronary with a Carrel patch. Because it was difficult to reconstruct the RCA with a Carrel patch, they performed bypass surgery for the RCA using a saphenous vein graft. Ten hours after the surgery, the patient’s blood pressure and heart rate dropped dramatically and she required cardiopulmonary resuscitation. The surgeons reopened her chest and detected a hematoma, but no active bleeding, around the distal anastomosis of the ascending aorta. They inserted an additional drainage tube around the ascending aorta. After reoperation, the patient’s vital signs recovered temporarily. Continuous hemodialysis was performed because of oliguria. On the following day, the blood pressure dropped gradually even though they were being administered high-dose catecholamines. The patient died 2 days after surgery.
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Discussion Even though the standard treatment for this condition is surgery [4], we did not use surgery to treat a patient with AMI due to type A aortic dissection in an emergency situation. There were two reasons for our decision not to perform emergency surgery. First, we were unable to diagnose AMI due to type A aortic dissection in the emergency department, even though we suspected this diagnosis and therefore performed emergency CT. However, her dissection was too limited to be identified by this procedure. Because the presentation of AMI with type A aortic dissection is similar to that of AMI without aortic dissection, the diagnosis of dissection is difficult in an emergency situation [5]. Japan AMI registry showed median door-to-balloon time was 42 min in emergency situation [16]. Second, the guidelines for treatment of aortic dissection are not based on good evidence. No randomized studies of medical versus surgical management for AMI due to aortic dissection have been performed. The
PCI for AMI due to type A aortic dissection Fig. 4 a, b CT images showing a giant aneurysm of the right sinus of Valsalva 1 month after stent placement. The white arrows show the aneurysm. c Short axis view of sinus of Valsalva. White arrows show the aneurysm. There is an entry point at RCC. d Long axis view of Valsalva. White arrows show the aneurysm. There is an entry point at the RCC. RCC right coronary cusp, LCC left coronary cusp, NCC non coronary cusp
guidelines recommending surgery for aortic dissection are based on reports of case series [17]. Some data show that medical management is better than surgical management in cases of thrombosed type A aortic dissection [18]. We thought that the patient’s condition suggested a thrombosed aortic dissection, and therefore treated her by PCI instead of surgery. To evaluate the usefulness of PCI in such cases, we have reviewed previous case reports of patients with AMI due to type A aortic dissection who were treated with PCI [6–15]. Table 1 shows all the reported cases. Most of these patients were in shock at the time of admission. Urgent diagnosis and treatment are essential; however, 50 % of cases were diagnosed after PCI. These data suggest that the diagnosis of AMI due to type A aortic dissection is difficult. Most of the cases were diagnosed by CT and several by transesophageal echocardiography. Among these patients, left main coronary artery lesions were more common than RCA lesions, even though type A aortic dissection usually involves the RCA. Because left main coronary artery lesions are much more severe than RCA lesions, they require emergency PCI. Most of the reported cases underwent surgery for the aortic dissection soon after PCI, and survived. Ikari [19] reported successful treatment with PCI for AMI after surgery of acute aortic dissection.
Clearly, PCI in patients with AMI caused by aortic dissection is potentially dangerous because it could exacerbate the dissection. In addition, PCI could delay surgical interventions. These case reports suggest that PCI is a good presurgical treatment option for critically ill patients with AMI due to type A aortic dissection. It is important to question why our patient developed an aneurysm. She had a history of type A aortic dissection, which had been treated medically. The entry site of the previous dissection was located 2.5 cm distal from the RCA. The previous aortic dissection had led to weakness of the tunica media between the aorta and the annulus fibrosis of the aortic valve [20]. This weakness of the aortic wall led to dilation of the sinus of Valsalva, which predisposed her to aortic dissection at this site. Dissection of the sinus of Valsalva extended to the inner layer of the RCA, leading to RCA occlusion. Thrombosed dissection was present before the PCI. We believed it might be possible to reopen the entry site with a catheter. Akutagawa [21] reported acute coronary occlusion by injured aortic valve with a catheter. We placed stents to restore RCA perfusion, but could not close the entry site of the aortic dissection with stents. Continued flow into the entry site therefore led to formation of the aneurysm. We used heparin and aspirin to prevent stent thrombosis; however, this antiplatelet therapy
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S. Kodera et al. Fig. 5 Bypass surgery and replacement of ascending aorta and aortic valve. Aneurysm at ostium of RCA. b Replacement of aortic valve and RCA bypass. c There is an aneurysm at the ostium of the RCA. d Entry site around the RCA
Table 1 Characteristics of reported cases who underwent stent placement for AMI due to type A aortic dissection Age, sex
Shock
Diagnosis before/after PCI
Diagnostic modality
Location of lesion
Number of stents
Operation
Outcome
74 M
-
After
TEE
LM
1
?
Alive
67 M
?
After
CT
LM
1
-
Dead
68 M
?
After
TEE
LM
1
-
Dead
41 M
?
After
CT
LM
2
?
Alive
71 M
?
Before
CT
RCA
1
?
Alive
69 M
?
After
IVUS
RCA
NA
?
NA
49 F
-
After
TEE
RCA
NA
?
Alive
62 M
?
Before
CT
RCA
2
?
Alive
67 F
-
After
CT
RCA
NA
?
Alive
57 M
?
Before
CT
LM
1
?
Alive
52 M
?
After
TEE
LM
1
?
Alive
AMI acute myocardial infarction, PCI percutaneous coronary intervention, TEE transesophageal echocardiography, LM left main coronary artery, CT computed tomography, IVUS intravascular ultrasonography, RCA right coronary artery, IVUS intravascular ultrasonography, NA not available
likely prevented closure of the entry site. The false lumen enlarged, forming an aneurysm of the sinus of Valsalva. We believe that PCI could be a good initial treatment option for critically ill patients with AMI due to type A aortic dissection. This is the first reported case of aneurysm formation after PCI for AMI with aortic dissection.
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