Diagnosis of coronary artery dissection following blunt chest trauma by transesophageal echocardiography

Myocardial contusion

Myocardial contusion can be a difficult diagnosis to make. There is currently no gold standard of investigation that allows its accurate diagnosis in the clinical setting. Trauma surgeons need to have a high degree of clinical suspicion when dealing with patients who have received blunt thoracic injuries in order that the diagnosis of myocardial contusion may be made. In this article we discuss the diagnosis, potential complications and investigation of patients with suspected myocardial contusion and also present a fl ow diagram for the possible management of patients with trauma who may have suspected myocardial contusion.

Coronary artery occlusion following blunt chest trauma: a case report and review of the literature

Blunt chest trauma causing coronary artery occlusion and myocardial infarction is a rare but potentially fatal condition. We present the case of a healthy 29-year-old man who developed a myocardial infarction due to complete occlusion of the proximal right coronary artery following blunt chest trauma. A review of the literature found 63 cases of previously healthy patients under 40 years of age who developed coronary artery occlusion following blunt chest trauma; diagnosis in all cases had been proven by angiography or during autopsy. The presentation, results of electrocardiography and echocardiography and laboratory findings of these patients are described.

Traumatic coronary artery dissection: a case report and literature review

BACKGROUND

Coronary artery dissection after blunt chest trauma is a rare, life-threatening condition.

OBJECTIVES

To present a case of coronary artery dissection after blunt chest trauma and to outline the appropriate management of this condition based on a literature review.

CASE REPORT

We report the case of a 50-year-old woman with traumatic coronary artery dissection after a high-speed motor vehicle collision. She presented to the Emergency Department via ambulance within a few hours of the collision, and her clinical condition deteriorated rapidly. A 12-lead electrocardiogram on arrival demonstrated anterolateral ST-segment elevation. The patient was intubated due to hypoxemic respiratory failure and she required inotropes for blood pressure support. Computed tomography imaging revealed pulmonary edema and right third and fourth rib fractures. Emergent angiography demonstrated dissection of her left main coronary artery, requiring placement of a stent.

CONCLUSION

Early recognition of this clinical entity with a screening electrocardiogram, and aggressive management, may result in a favorable outcome. A literature review reveals that coronary artery bypass grafting, angiography with stent placement, and conservative management may all be considered viable treatment options for this condition.

[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.

Pregnancy-associated coronary artery dissection: A case report

We describe the case of a 38-year-old woman who presented with a chief complaint of chest heaviness approximately 2 weeks postpartum. She was otherwise healthy with no cardiac risk factors. Coronary angiography revealed a spiral dissection of the left main coronary artery that extended to the left anterior descending coronary artery. Pregnancy-associated coronary artery dissection is a disease that has in the past carried a high mortality rate. Even today many women die before reaching medical help. Early diagnosis and intervention are crucial. Percutaneous transluminal coronary angioplasty for single vessel disease and coronary artery bypass grafting for multi-vessel disease are becoming the treatments of choice.

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.

Circumflex coronary artery occlusion after blunt chest trauma

A 32-year-old white male police officer suffered blunt trauma to the anterior chest wall during a routine training session. This was accompanied by the precipitous onset of chest discomfort. There was no previous history of any cardiac risk factors. The diagnosis of an inferior wall myocardial infarction was made based on the electrocardiogram findings, at his local community hospital. The total creatine kinase, creatine kinase-MB, and troponin I were normal. The transesophageal echocardiogram performed at that time demonstrated no aortic or coronary dissection. He was transferred to our tertiary care center. Emergency cardiac catheterization demonstrated lateral wall hypokinesis with a left ventricular ejection fraction of 45% and a total occlusion of the left circumflex coronary artery in its proximal portion. This was successfully recannulized with angioplasty and stenting techniques. We believe this to be only the second reported case of circumflex coronary artery obstruction after blunt chest trauma.

Transesophageal echo detection of postpartum coronary artery dissection

A 40-year-old woman, 1 week postpartum, presented with an acute anterior-septal myocardial infarction, caused by an intrawall hematoma (dissection without intimal flap) in her proximal left anterior descending coronary artery-the diagnosis being initially suggested by transesophageal echo. Discussion of this entity follows.

Concomitant Traumatic Coronary Artery and Tricuspid Valve Injury: A Heterogeneous Presentation

Blunt thoracic trauma resulting in both tricuspid valve rupture and coronary artery injury is uncommon, encompasses a large spectrum of presentations and, therefore, can be difficult to diagnose. This report illustrates the heterogeneous presentation and clinical course of two patients with such a combination of cardiac injuries. The patient with associated right coronary artery dissection developed progressive right ventricular failure over a 12-year period before successful surgical repair, whereas another patient with left anterior descending coronary artery thrombosis required urgent operation for acute right ventricular dysfunction and hemodynamic decompensation.

Right coronary artery dissection and acute infarction due to blunt trauma: report of a case

Coronary artery dissection occurring after a nonpenetrating chest trauma is extremely rare. We describe herein the case of a 43-year-old man who suffered traumatic myocardial infarction after an intimal tear of the right coronary artery had been inflicted by a horse stepping on his back.

Circumflex coronary artery dissection following waterskiing

A previously healthy 35-year-old woman experienced chest discomfort following mild blunt chest trauma while waterskiing. During the following 48 h, she underwent evaluation in two separate emergency departments (EDs) where she was found to have normal ECGs and cardiac enzyme values. She was subsequently discharged from both EDs. Twelve hours after the second ED visit, she was discovered unconscious at home and was resuscitated from ventricular fibrillation. Emergency cardiac catheterization demonstrated moderate circumflex disease without angiographic evidence of a false lumen or intimal flap. Left ventriculography demonstrated posterolateral wall hypokinesis. Eight days after remaining ventilator-dependent and unconscious, the patient was declared brain-dead. At autopsy, the patient was found to have a dissection of the circumflex artery. Waterskiing is an unusual source of cardiac trauma; however, we believe this to be the first reported case of dissection in the circumflex artery following blunt chest trauma.

Traumatic ventricular septal defect

A 26 year old man was admitted to hospital following a traffic accident. He had been sitting in the back of a car without wearing a seat belt. He suffered crush injuries on the anterior chest wall, trunk, and legs. On admission he was awake and cooperative, but restless, and obviously in severe pain. Radiography of the skull, facial bones, chest, spine, pelvis, and legs revealed a shaft fracture of the left femur and tibia and fracture of the 7th and 8th right ribs. The patient was transferred to the University Hospital of Zurich for further assessment and surgical repair of the lower limb fractures three days later. Because of worsening clinical condition with onset of partial respiratory insufficiency and new loud systolic murmur at the left sternal edge, a transthoracic echocardiography was performed, which showed an apical ventricular septal defect. Surgery was performed immediately. The ventricular septal defect was successfully repaired using a Teflon felt patch and interrupted sutures with pledgets, and sealed with glue. At six months' follow up the patient was doing well. Ventricular septal defects after blunt chest trauma occur either because of heart compression between sternum and the spine or because of myocardial infarction. In the present case the ventricular septal defect appeared three days after the accident, probably secondary to a post-traumatic myocardial infarction. Patients with blunt chest trauma and suspicion of cardiac contusion should be monitored carefully.