CASE REPORT AND REVIEW OF THE LITERATURE CARDIOLOGY // LEGAL MEDICINE Traumatic Coronary Dissection: Case Presentation and Literature Review Arthur A. Keresztesi 1,2 , Gabriela Asofie 1,3 , Harald Jung 2 1 University of Medicine and Pharmacy, Tîrgu Mureș, Romania 2 Institute of Legal Medicine, Tîrgu Mureș, Romania 3 3 rd Medical Clinic, Tîrgu Mureș, Romania CORRESPONDENCE ABSTRACT Gabriela Asofie In posttraumatic coronary dissection, a small intimal tear occurs due to the sudden compres- Str. Gheorghe Marinescu nr. 50 sion of the thoracic wall during the chest trauma, this being sometimes fatal. We present the 540136 Tîrgu Mureș, Romania case of a 56-year-old truck driver with chest trauma after a car crash. The 12-lead ECG showed Tel: +40 757 927 574 signs suggestive of an acute anterior myocardial infarction, and the coronary angiography Email: gabriela_asf@yahoo.com confjrmed an arterial dissection of the left anterior descending coronary artery. A stent was inserted the same day, and the patient was treated accordingly. He survived for a total of three days. The autopsy and histological examination confjrmed the MI and the coronary dissection. ARTICLE HISTORY The chest trauma was linked to the patient’s death. The literature review reveals 46 cases in Received: 5 November, 2016 which the most frequent cause of chest trauma was a car or motorcycle accident; also, young Accepted: 11 November, 2016 male subjects were more frequently involved. Stent placement was the main course of treat- ment, and a delay in the onset of symptoms was also frequent. Keywords: post-traumatic coronary dissection, sudden death, myocardial infarction, chest trauma INTRODUCTION Cardiac injury secondary to a chest trauma is not uncommon and may lead to various symptoms, from simple arrhythmias to myocardial infarction due to cor- onary dissection or even fatal cardiac rupture. 1 Posttraumatic coronary dissec- tion is a rare entity, and not many cases are reported in the literature. A possible reason for the small number of cases could be sudden death occurs in many of these patients. 2 Tie small intimal tear caused by the sudden compression of the thoracic wall during the chest trauma, may evolve under the hemodynamic stress and, associ- ated with the disruption of the endothelial lining, may lead to coronary throm- bosis and acute myocardial infarction (MI). Tie lefu anterior descending (LAD) artery is the most commonly afgected branch (76%), mainly due to its position close to the chest wall, followed by the right coronary artery (12%) due to its anterior position toward the sternum dur- Arthur A. Keresztesi • Str. Gheorghe Marinescu nr. 50, 540136 Tîrgu Mureș, Romania. Tel: +40 265 215 551 Harald Jung • Str. Gheorghe Marinescu nr. 38, 540142 Tîrgu Mureș, Romania. Tel: +40 265 215 240 Journal of Interdisciplinary Medicine 2016;1(3):282-286 DOI: 10.1515/jim-2016-0057 Unauthenticated Download Date | 1/17/17 2:55 PM
Journal of Interdisciplinary Medicine 2016;1(3):282-286 283 ing systole. Finally, the least involved is the lefu circumfmex Abnormal autopsy findings artery (6%). 2–4 A medicolegal autopsy was performed. Tie external exam- ination found a 15 × 5 cm ecchymosis in the lefu infracla- CASE REPORT vicular region, probably from the car crash, needle marks A 56-year-old male truck driver with chest trauma afuer a on the right arm, forearm and right inguinal region. Also, car crash presented with prolonged chest pain, followed on the right and lefu sides of the anterior thoracic region, by ventricular fjbrillation and cardiac arrest, one hour af- roundish brown signs from defjbrillation were present. ter the accident. He was successfully resuscitated at the Tie internal examination revealed a C3–C4 sternum place of the accident and was transported to the nearest fracture, multiple rib fractures on both sides (we interpret- emergency hospital. Tioracic CT revealed an inferior ed some of them as being secondary to cardiopulmonary sternum fracture, the fracture of the 4 th and 5 th ribs on resuscitation, and others to the car crash). In the pericar- the right, and minimal bilateral pulmonary contusions. dium, 600 ml of red blood clots were present; the anterior Tie 12-lead ECG revealed a 3 mm ST segment elevation wall of the lefu atrium and ventricle presented blood infjl- in the anterior leads (V1–V3), while the coronary angi- trate and fjne cardiac muscle ruptures. On the section of the ography showed a 15 mm dissection of the proximal S1 heart, a yellowish 6.5 × 1.2 cm area with rare hemorrhagic segment of the LAD artery with TIMI I fmow. Four hours lines extended from the anterior 1/3 of the septum to the afuer the car crash, the patient had a 3 × 15 mm metal anterior wall of the lefu ventricle (Image 1A). In the lumen stent implanted. Tie following day, the ECG recording of the LAD artery, 8 mm from the lefu main coronary artery, revealed pathological Q waves in V1–V3, 5 mm ST seg- a 15 mm permeable stent was present, with non-signifjcant ment elevation with T-wave changes in DI and aVL, 5 mm atherosclerosis before and afuer the stent (fjrst-degree coro- ST depression and T-wave changes in DIII and aVF. Tie nary atherosclerosis, isolated fatty streaks). patient’s blood pressure was constantly low during the Histopathological examination with hematoxylin-eo- second day, with values between 75/50 mmHg and 85/90 sin stain revealed severe interstitial myocarditis, an acute mmHg, therefore dobutamine 5 μg/kg/min was admin- myocardial infarction that occurred 24–72 hours before istered. Tie cardiac enzymes were elevated. On the third death. Tie coronary artery examination showed hemor- day, the patient’s blood pressure was still low, and cardiac rhagic infjltrate in the epicardium, as well as coronary ath- enzymes were continuously rising, creatin-kinase 2900 erosclerosis. U/L, liver enzymes AST-ALT ~3000 U/L. Dobutamine We concluded that the cause of death was a recent myo- continued to be administered. Tiat evening, the patient cardial infarction due to the dissection of the lefu coronary presented a cardiac arrest with asystole, with no response artery following a chest trauma. We also established a di- to cardiopulmonary resuscitation, being pronounced rect causal link between the traumatic lesions and the pa- dead an hour later. tient’s death. IMAGE 1. A – Myocardial infarction on the septum and anterior wall of the heart; B – Myocardial infarction with inflammatory and haemorrhagic infiltrate, haematoxylin-eosin stain, 50×. Unauthenticated Download Date | 1/17/17 2:55 PM
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