Acute coronary artery occlusion secondary to blunt chest trauma

Delayed cardiac tamponade in a patient with previous minor blunt chest trauma

Hemopericardium with cardiac tamponade after non-penetrating chest trauma is a very rare but life-threatening condition. If this complication develops after an interval of several weeks following the non-penetrating chest trauma, the causal relation with the traumatic event is less evident, which may delay proper diagnosis and adequate treatment. We describe diagnosing and therapeutic management of a patient in shock who suffered from cardiac tamponade four weeks after a minor blunt chest trauma.

[Coronary dissection and non-penetrating chest trauma]

The occurrence of an acute myocardial infarction after non-penetrating chest trauma is an extremely rare complication. We report a case of dissection of the left anterior descending artery in a 43 year old man after being punched in the chest. Using data from a literature search relish revealed 76 cases; we review the characteristics of the pathology and its incidence. We also characterize its etiology, anatomy and path physiology. We then consider the diagnostic and therapeutic implications.

Prior blunt chest trauma may be a cause of single vessel coronary disease; hypothesis and review

Prompted by a case where a patient (with no risk factors, and single vessel disease) developed angina pectoris after previous blunt chest trauma, we searched Medline for blunt chest trauma and myocardial ischaemia. We found 77 cases describing AMI after blunt chest trauma, but only one reporting angina pectoris. We focused on the age and sex distribution, type of trauma, the angiography findings and the time interval between the trauma and the angiography. The age distribution was atypical, compared to AMI in general; 82% of the patients with AMI after blunt chest trauma were less than 45 years old, and only 2.5% more than 60 years old. The most common trauma was a road traffic accident, and the LAD was the vessel most often affected. Angiography revealed 12 cases with completely normal vessels, which might be due to spasm or recanalisation; 31 cases showed occlusion but no atherosclerosis, which strongly suggested a causal relation between the trauma and subsequent occlusion. AMI should therefore be considered in patients suffering from chest pain after blunt chest trauma. Because traumatic AMI might often be the result of an intimal tear or dissection, thrombolytic therapy might worsen the situation and acute PCI must be considered preferable. It seems likely that lesser damage could lead to longer-term stenosis we suspect that this sequence is grossly under-reported. This could have medico-legal implications.

Mathematical model of blunt injury to the vascular wall via formation of rouleaux and changes in local hemodynamic and rheological factors. Implications for the mechanism of traumatic myocardial infarction

Background

Blood viscosity is fundamentally important in clinical practice yet the apparent viscosity at very low shear rates is not well understood. Various conditions such as blunt trauma may lead to the appearance of zones inside the vessel where shear stress equals zero. The aim of this research was to determine the blood viscosity and quantitative aspects of rouleau formation from erythrocytes at yield velocity (and therefore shear stress) equal to zero. Various fundamental differential equations and aspects of multiphase medium theory have been used. The equations were solved by a method of approximation. Experiments were conducted in an aerodynamic tube.

Results

The following were determined: (1) The dependence of the viscosity of a mixture on volume fraction during sedimentation of a group of particles (forming no aggregates), confirmed by published experimental data on the volume fractions of the second phase (f₂) up to 0.6; (2) The dependence of the viscosity of the mixture on the volume fraction of erythrocytes during sedimentation of rouleaux when yield velocity is zero; (3) The increase in the viscosity of a mixture with an increasing erythrocyte concentration when yield velocity is zero; (4) The dependence of the quantity of rouleaux on shear stress (the higher the shear stress, the fewer the rouleaux) and on erythrocyte concentration (the more erythrocytes, the more rouleaux are formed).

Conclusions

This work represents one of few attempts to estimate extreme values of viscosity at low shear rate. It may further our understanding of the mechanism of blunt trauma to the vessel wall and therefore of conditions such as traumatic acute myocardial infarction. Such estimates are also clinically significant, since abnormal values of blood viscosity have been observed in many pathological conditions such as traumatic crush syndrome, cancer, acute myocardial infarction and peripheral vascular disease.

A successfully treated case of blunt traumatic right coronary ostium rupture

Cardiac tamponade due to coronary artery rupture, as a consequence of blunt trauma, is a rare but usually fatal condition. We successfully obtained primary hemostasis with emergency room thoracotomy, followed by delayed definitive treatment of the ruptured right coronary artery ostium in a motor vehicle accident victim with multifocal hemorrhagic lesions. Survival of patients with the described serious trauma has not been reported, and we discuss herein our treatment strategy.

Acute anterior myocardial infarction following a mild nonpenetrating chest trauma--a case report

Myocardial infarction in patients under age 45 years is a relatively unusual phenomenon; blunt chest trauma is one of the nonatherosclerotic mechanisms leading to acute myocardial infarction in young adults. The authors report a rare case of anterior myocardial infarction in a 22-year-old man following a mild nonpenetrating chest trauma whose left chest was elbowed during a soccer game.

Coronary artery occlusion and myocardial infarction: a seldom encountered complication of blunt chest trauma

Myocardial infarction is a rare complication that can occur after blunt chest trauma. The authors describe a 30-year-old man who experienced a fatal anterolateral myocardial infarction after chest trauma in a motorcycle accident. The electrocardiogram and creatine phosphokinase-MB isoenzymes levels suggested myocardial necrosis. Tc-99m phosphate myocardial scintigraphy identified an extensive doughnut-shaped uptake over the cardiac area. An echocardiogram revealed severe left ventricular impairment. Coronary angiography confirmed complete occlusion of the proximal left anterior descending coronary artery.

Thrombosis and cardiovascular disease

The early stages of venous thrombosis originate at selective sites of reduced blood flow in the apices of venous valves. Stagnation of venous flow results in the formation of a platelet-fibrin thrombus, which serves as the nidus for thrombus propagation. Stasis alone, however, does not result in thrombosis necessarily. The presence of activated coagulation factors is essential. The major predisposing factors to venous thrombus are activation of blood coagulation and venous stasis. In contrast to venous thrombus formation, vascular abnormalities are the most important causative factor in arterial thrombosis.

Posttraumatic myocardial infarction with severe coronary intimal dissection documented by intravascular ultrasound

We present a case of posttraumatic myocardial infarction after blunt chest trauma in a previously healthy man. Coronary angiography showed an eccentric occlusion in the midportion of the left anterior descending artery. Subsequent intracoronary ultrasound imaging revealed a severe intimal dissection. The outcome after intracoronary stent placement was excellent. This rare but potentially harmful complication of blunt chest trauma should be kept in mind and coronary angiography performed immediately when coronary occlusion is suspected. Intravascular ultrasound imaging is a helpful tool in the assessment of coronary artery occlusion caused by intimal dissection.

Posttraumatic coronary artery aneurysm

A 31-year-old man sustained blunt deceleration trauma with dissection of the left anterior descending coronary artery. We repaired a posttraumatic coronary aneurysm to prevent late occlusion of the recanalized vessel. An internal mammary artery graft was applied as a precaution against postoperative thrombosis. Follow-up at 12 months showed improved left ventricular function.

Right coronary artery occlusion secondary to blunt trauma

The heart lies in a vulnerable position when the chest is subjected to direct blunt trauma. Acute occlusion of a coronary artery from blunt chest trauma is rare, with occlusion of the right coronary artery at its origin recorded only twice in the English literature. A young male unrestrained driver sustained an acute deceleration injury with significant chest trauma when he crashed, crushing the steering wheel against his chest. Creatine phosphokinase isoenzymes were initially 2% of the total and 8% 12 h later. There were marked electrocardiographic changes, and an echocardiogram revealed abnormal left ventricular systolic function with an akinetic inferior-posterior wall and right ventricular enlargement. A wide mediastinum and mechanism of injury led to the performance of aortography which failed to disclose a right coronary vessel. Subsequently coronary angiography confirmed acute occlusion of the proximal right coronary artery. Because of other associated injuries, nonoperative medical management was successfully utilized.

Diagnosis, Management, and Complications of Nonpenetrating Cardiac Trauma: A Perspective for Practicing Clinicians

We provide a state-of-the-art review for practicing clincians concerning diagnosis and treatment of patients with non-penetrating cardiac trauma. Internists, cardiologists, and intensivists are becoming increasingly involved in the diagnosis and management of patients with nonpenetrating cardiac injuries. Electrocardiography and cardiac isoenzyme determinations are the least expensive and most common laboratory tests used to diagnose this condition. Despite widespread use, however, these tests have significant limitations in diagnostic sensitivity and specificy. Two-dimensional echocardiography is advocated by some to improve diagnostic accuracy and to identify patients at increased risk of cardiovascular complications. Patients identified as low risk may be suitable for limited monitoring and early hospital discharge. Transesophageal echocardiography is a useful diagnostic tool that offers many advantages over standard transthoracic imaging. Nuclear medicine techniques, including radionuclide-labeled antimyosin scanning, also represent exciting new developments in this area. Invasive techniques such as cardiac catheterization and pumonary artery catheterization should be reserved for patients with hemodynamic instability and overt mechanical complications. Appropriate selection of diagnostic tests can assist clinicians in rapid traging of patients with nonpenetrating cardiac trauma. Identification of patients at low risk for cardiovascular complications may lead to more appropriate use of hospital resources.

Angiographically documented thrombotic coronary artery occlusion secondary to mild nonpenetrating thoracic trauma

A 22-yr-old man was found to have a subtotally occluding thrombus in the proximal left anterior descending (LAD) coronary artery shortly after suffering mild blunt chest trauma. After 6 days of anticoagulant therapy, the LAD appeared angiographically normal.

Acute myocardial infarction after blunt chest trauma in young people: need for prompt intervention

We describe four cases of acute myocardial infarction in young patients, secondary to blunt chest trauma. One case was treated with intracoronary thrombolysis and angioplasty, two cases received systemic thrombolysis, and the last one did not have any reperfusion therapy. The coronary angiograms of the left anterior descending artery showed thrombosis in two cases, coronary dissection in one case, and no morphological lesions in the other. We encourage the early performance of angiographic studies in these patients, adjusting the therapy to their pathophysiologic mechanism.

Traumatic thrombosis of the left main coronary artery and myocardial infarction caused by blunt chest trauma

We report the case of a 38-year-old man who, after a blunt chest trauma, developed an acute transmural myocardial infarction. Coronary arteriography revealed a thrombus in the left main artery, occlusion of the distal left anterior descending artery, and a diagonal branch caused by emboli.

Myocardial infarction caused by blunt chest injury: possible mechanisms involved--case reports

Two cases are reported in which blunt chest trauma caused myocardial infarction. Coronary angiography revealed apical aneurysms in both patients with normal coronary arteries in the first and total occlusion of left anterior descending artery in the other. The main possible mechanisms of myocardial infarction after blunt chest trauma are discussed.

Coronary artery dissection secondary to blunt chest trauma

A 38-yr-old woman presented with an anterolateral myocardial infarction following blunt chest trauma sustained in a motor vehicle accident. Subsequent cardiac catheterization revealed a large left ventricular aneurysm and angiographic evidence of dissection of the proximal left anterior descending artery. Review of the literature and management are discussed.

Myocardial infarction caused by coronary artery damage from blunt chest injury

A case is reported in which blunt chest injury caused an intimal tear in the left anterior descending coronary artery. Despite few external signs of injury the patient sustained a myocardial infarction resulting in life threatening arrhythmias and considerable left ventricular dysfunction.

[Blunt heart injuries]

Cardiac injuries were present in 16% of our patients suffering from blunt chest trauma. 25% of these cases had no concomitant rib fractures. Sonography is extremely important for evaluation. In myocardial contusion the electrocardiogram reveals mainly disturbances in repolarisation (66 out of 108 patients) and rhythm disturbances (59 patients). A ratio of CK-MB isoenzyme/total CK of over 8% is highly suggestive of myocardial injury. Continuous monitoring in ICU is mandatory. Prognosis is mainly based on additional injuries. Heart wall rupture and luxation of the heart require operative treatment. Lesions of the aortic valves are the most frequent valve injuries.

Myocardial infarction after blunt chest trauma incurred during rugby football that later required cardiac transplantation

A 28 year old man sustained an extensive anterolateral myocardial infarction five minutes after a blow on the chest while playing rugby football. The resulting persistent cardiac failure necessitated orthotopic cardiac transplantation.

Current status of coronary artery bypass grafting for coronary artery atherosclerosis

Coronary artery bypass grafting has now undergone 18 years of proven benefit in the treatment of myocardial ischemic disease. The technique of CABG has been further extended to other situations in which myocardial blood supply is threatened, such as cardiac trauma, aneurysms of coronary arteries, and congenital lesions. The emphasis in choosing CABG over medical therapy in 1985 should be preservation of myocardium at jeopardy of infarction as well as relief of angina. Proximal stenoses in vessels subserving viable muscle that is ischemic at rest or with minimal exercise should be treated with reperfusion by angioplasty or CABG to prevent further injury. After infarction occurs and ventricular function is impaired, CABG is also necessary to preserve remaining myocardium at jeopardy. Such an aggressive approach seems warranted with today's excellent surgical results. Long-term results have also improved, as more attention has been paid to saphenous vein graft preparation, use of mammary artery grafts, complete revascularization, use of antiplatelet agents, control of spasm, and identification of hypercoagulable states that may require sodium warfarin (Coumadin). Angioplasty of vein grafts and distal anastomoses also appears promising to help extend the results of initial CABG. Figure 1 is our recommended approach for the treatment of coronary atherosclerosis.

Acute left anterior descending coronary artery occlusion following blunt chest injury

A case of acute coronary artery occlusion following blunt chest injury is reported. The incidence, cause and management of this injury are reviewed.

Coronary artery obstruction due to blunt chest trauma with residual angina pectoris

A 41-year-old man developed persistent angina pectoris following blunt trauma to his chest. Three months after the injury coronary angiography demonstrated 80% obstruction of the mid-left anterior descending coronary artery. There was no evidence of atherosclerosis in the remaining coronary arteries. Therefore the assumption is made that blunt trauma can induce incomplete coronary occlusion resulting in classic angina pectoris in apparently otherwise normal coronary arteries. The suggested mechanism of injury to the coronary vessel is either intimal tear and/or subintimal hemorrhage with incomplete luminal thrombosis.