Abstract
Coronary artery injury after blunt chest trauma is rare, but can be life-threatening, resulting in severe myocardial ischaemia and acute myocardial infarction. We report a case of a 56-year-old male who presented a few days after a blunt chest trauma with crescendo unstable angina. Coronary angiography demonstrated left main coronary artery dissection that was fixed with stent implantation. After a blunt chest trauma symptoms and electrocardiographic findings of a coronary dissection can be nonspecific and confounded by the chest tenderness. In such cases careful evaluation to rule out traumatic coronary injuries is warranted and early intervention should not be delayed in the presence of clear evidence of myocardial ischemia.
1
Introduction
Blunt chest trauma is frequently associated with a list of complications like pneumothorax, rib fractures, lung perforation, liver and spleen ruptures, cardiac contusion with pericardial effusion or tamponade and vascular injuries . Coronary injures can be found in a very small percentage of patients , but these cases are often recognized and treated late because traumatic chest pain sometimes masks angina pain and distracts physicians from recognizing potentially devastating complications like left main or proximal LAD dissection/rupture. We present a case of severe blunt chest trauma complicated by left main coronary dissection with a sneaky presentation leading to delayed diagnosis and treatment.
2
Case report
A 56-year-old man was admitted to our Hospital for worsening anginal attacks (typical anginal pain for minimal efforts, diffuse ST depression at 12-lead ECG) without biomarker alterations, occurring 7 days after a blunt chest trauma (overturning of a farm tractor). The patient was obese, had quit smoking for 5 years and was in medical treatment for arterial hypertension with an ACE-inhibitor.
After the chest trauma the patient was evaluated a first time in our institutional ED. Chest X ray showed X and XI right rib fractures, right pneumothorax and a small pericardial effusion, but 12-lead ECG was unremarkable and cardiac troponin I (cTnI) curve was negative for myocardial infarction. Moreover echocardiography showed no left or right ventricular regional wall abnormalities. The pneumothorax was drained and patient was discharged with broad spectrum antibiotics, NSAID and codeine prescription.
When the pain due to chest compression improved and mobilization began the patient recognized another symptom, a chest oppression associated with even minimal efforts. Thus he referred again to the ED where sampling for cTnI continued to be negative and a new ECG showed sinus tachycardia with diffuse ST segment depression and negative T waves from V1 to V6 ( Fig. 1 ). At admission the patient was slightly hypertensive (150/90 mmHg), heart rate was 80 bpm, neither jugular engorgement nor calf oedema was present, lungs were clear and a 4th heart sound was audible without other cardiac murmurs. A large thoracic graze with bruise and chest tenderness was evident. The patient was admitted to CCU and scheduled for urgent cardiac catheterization. Coronary angiography undisclosed left main (LM) dissection with aneurismal dilatation ( Fig. 2 , panel A and B) and IVUS imaging confirmed the presence of a large and irregular intimal flap arising from an eccentric atheroma of the middle-distal left main ( Fig. 3 ). Cardiac surgeon on ward refused the case due to the recent chest wall trauma with serious concerns about the possibility to use the internal thoracic arteries for bypass conduits. Thus the patient received an oral load of aspirin 300 mg and clopidogrel 600 mg and direct coronary stenting of the LM with a bare metal stent (Multilink Zeta 5.0 × 18 mm) optimized with high pressure oversized balloon dilation was performed, with optimal final angiographic result ( Fig. 2 panel C, D and E). The patient was discharged without complications the following day, with a prescription for 6-month double antiplatelet therapy (DAPT). Two year clinical and angiographic follow up was unremarkable ( Fig. 2 panel F).
2
Case report
A 56-year-old man was admitted to our Hospital for worsening anginal attacks (typical anginal pain for minimal efforts, diffuse ST depression at 12-lead ECG) without biomarker alterations, occurring 7 days after a blunt chest trauma (overturning of a farm tractor). The patient was obese, had quit smoking for 5 years and was in medical treatment for arterial hypertension with an ACE-inhibitor.
After the chest trauma the patient was evaluated a first time in our institutional ED. Chest X ray showed X and XI right rib fractures, right pneumothorax and a small pericardial effusion, but 12-lead ECG was unremarkable and cardiac troponin I (cTnI) curve was negative for myocardial infarction. Moreover echocardiography showed no left or right ventricular regional wall abnormalities. The pneumothorax was drained and patient was discharged with broad spectrum antibiotics, NSAID and codeine prescription.
When the pain due to chest compression improved and mobilization began the patient recognized another symptom, a chest oppression associated with even minimal efforts. Thus he referred again to the ED where sampling for cTnI continued to be negative and a new ECG showed sinus tachycardia with diffuse ST segment depression and negative T waves from V1 to V6 ( Fig. 1 ). At admission the patient was slightly hypertensive (150/90 mmHg), heart rate was 80 bpm, neither jugular engorgement nor calf oedema was present, lungs were clear and a 4th heart sound was audible without other cardiac murmurs. A large thoracic graze with bruise and chest tenderness was evident. The patient was admitted to CCU and scheduled for urgent cardiac catheterization. Coronary angiography undisclosed left main (LM) dissection with aneurismal dilatation ( Fig. 2 , panel A and B) and IVUS imaging confirmed the presence of a large and irregular intimal flap arising from an eccentric atheroma of the middle-distal left main ( Fig. 3 ). Cardiac surgeon on ward refused the case due to the recent chest wall trauma with serious concerns about the possibility to use the internal thoracic arteries for bypass conduits. Thus the patient received an oral load of aspirin 300 mg and clopidogrel 600 mg and direct coronary stenting of the LM with a bare metal stent (Multilink Zeta 5.0 × 18 mm) optimized with high pressure oversized balloon dilation was performed, with optimal final angiographic result ( Fig. 2 panel C, D and E). The patient was discharged without complications the following day, with a prescription for 6-month double antiplatelet therapy (DAPT). Two year clinical and angiographic follow up was unremarkable ( Fig. 2 panel F).
