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Left Anterior Descending Coronary Artery Occlusion Secondary to Blunt Chest Trauma

2009; Lippincott Williams & Wilkins; Volume: 119; Issue: 14 Linguagem: Inglês

10.1161/circulationaha.108.832824

1524-4539

Sachin S. Goel, James E. Harvey, Marc S. Penn, Venu Menon,

Traumatic Ocular and Foreign Body Injuries

HomeCirculationVol. 119, No. 14Left Anterior Descending Coronary Artery Occlusion Secondary to Blunt Chest Trauma Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBLeft Anterior Descending Coronary Artery Occlusion Secondary to Blunt Chest Trauma Sachin S. Goel, MD, James E. Harvey, MD, Marc Penn, MD, PhD and Venu Menon, MD Sachin S. GoelSachin S. Goel From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio. , James E. HarveyJames E. Harvey From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio. , Marc PennMarc Penn From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio. and Venu MenonVenu Menon From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio. Originally published14 Apr 2009https://doi.org/10.1161/CIRCULATIONAHA.108.832824Circulation. 2009;119:1975–1976A 17-year-old young man was setting off fireworks on July 4th when the base of the artillery shell blew off and struck him in the chest, knocking him to the ground. An ECG obtained in the emergency room at a local hospital showed 4-mm ST-segment elevation in leads V1 through V5, I, and aVL with pathological Q waves, complete right bundle-branch block, and a left anterior hemiblock (the Figure). Computed tomography scan of the chest revealed a comminuted sternal body fracture with a retrosternal hematoma, right-sided pneumothorax, and bilateral pulmonary contusions (the Figure). Laboratory data showed a creatine kinase of 9884 U/L, creatine kinase-MB of 846 ng/mL, and troponin T of 92 ng/mL. A transthoracic echocardiogram showed a markedly reduced left ventricular ejection fraction of 25% with hypokinesis of the distal septum and apex, normal right ventricular size and function, mild aortic, mitral and tricuspid regurgitation, and no pericardial effusion. He was managed conservatively for myocardial contusion. Because of hemodynamic instability and failure to wean off the ventilator, the patient was then transferred to our institution for further management 2 weeks after initial presentation. Download figureDownload PowerPointFigure. Top left, ECG on presentation demonstrating a 3- to 4-mm ST-segment elevation in leads V1 through V5, I, and aVL with Q waves, complete right bundle-branch block, and a left anterior hemiblock. Top right, Computed tomography of the chest demonstrating bilateral lung contusions (arrows) and right-sided pneumothorax (double arrow). Bottom left, Coronary angiogram demonstrating totally occluded left anterior descending coronary artery after the first diagonal branch (arrow). Bottom right, Transesophageal echocardiogram demonstrating an eccentric anteromedial jet of mitral regurgitation (arrow).ECG and echocardiographic findings led us to perform a coronary angiogram that revealed a totally occluded large proximal left anterior descending coronary artery after the first diagonal branch (the Figure). Other coronaries were normal. A transesophageal echocardiogram showed mild eccentric regurgitant jets in the mitral (the Figure) and tricuspid valves resulting from ruptured chordae with severe global left ventricular dysfunction (ejection fraction, 25%). Afterload reduction therapy for heart failure with intravenous vasodilators was initiated, and the patient was weaned off the ventilator. Mechanical recanalization of the infarct-related artery was not performed, but an implantable cardioverter-defibrillator was placed for prevention of sudden cardiac death. He was discharged home in a stable condition on a β-blocker and an angiotensin-converting enzyme inhibitor.Acute coronary artery occlusion following blunt chest trauma is a rare complication. Our case highlights the importance of having a high index of suspicion for coronary occlusion following blunt chest injury. The artery most commonly involved is the left anterior descending coronary artery.1 The causative mechanisms of coronary occlusion after blunt chest trauma are hypothesized to involve crushing of the artery between the sternum and the spine, vascular spasm, dissection with thrombus formation, or rupture of an existing plaque with thrombus formation. Cardiac contusion can present similarly with elevated cardiac enzymes and ECG and transesophageal echocardiogram abnormalities suggestive of myocardial infarction.2 This indicates the significance of having a strong clinical suspicion of coronary occlusion to make a decision regarding emergent coronary angiography in patients presenting with blunt chest trauma.DisclosuresNone.FootnotesCorrespondence to Venu Menon, MD, Director, Coronary Care Unit, Cleveland Clinic, J1–5, 9500 Euclid Ave, Cleveland, OH 44195. E-mail [email protected]References1 Wall MJ Jr, Mattox KL, Chen CD, Baldwin JC. Acute management of complex cardiac injuries. J Trauma. 1997; 42: 905–912.CrossrefMedlineGoogle Scholar2 Sybrandy KC, Cramer MJ, Burgersdijk C. Diagnosing cardiac contusion: old wisdom and new insights. Heart. 2003; 89: 485–489.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Huis in 't Veld M, Craft C and Hood R (2018) Blunt Cardiac Trauma Review, Cardiology Clinics, 10.1016/j.ccl.2017.08.010, 36:1, (183-191), Online publication date: 1-Feb-2018. Kara H, Avcı A, Akinci M, Degirmenci S, Bayir A and Ak A (2014) Blunt chest trauma as a cause of acute myocardial infarction, Acta Clinica Belgica, 10.1179/2295333714Y.0000000047, 69:5, (367-370), Online publication date: 1-Oct-2014. Sun L, Li Z, Zhao Y, Han J and Henein M (2012) Left anterior descending artery occlusion secondary to blunt chest trauma diagnosed by comprehensive echocardiography and coronary angiography, Journal of Clinical Ultrasound, 10.1002/jcu.21907, 40:6, (370-374), Online publication date: 1-Jul-2012. Bock J and Benitez R (2012) Blunt Cardiac Injury, Cardiology Clinics, 10.1016/j.ccl.2012.07.001, 30:4, (545-555), Online publication date: 1-Nov-2012. April 14, 2009Vol 119, Issue 14 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.108.832824PMID: 19364990 Originally publishedApril 14, 2009 PDF download Advertisement SubjectsAcute Coronary SyndromesCongenital Heart DiseaseMyocardial Infarction