• Massive myocardial infarction due to the complete occlusion of the left anterior descending coronary artery after blunt chest trauma

    A 27-year-old previously healthy woman was involved in a motor vehicle accident and experienced a blunt chest trauma due the airbag deployment. She was driving her car at 80 km/h when she crashed into a truck which was coming from the opposite direction. On physical examination, she was hemodynamically stable and hypoxic (oxygen saturation 88% on room air). She referred oppressive sternal chest pain and trafictive pain in the lower part of the right chest cage. Chest X-ray demonstrated absence of pulmonary contusions while the Extended Focused Assessment with Sonography for Trauma (E-FAST) showed absence of cardiac effusion, pneumothorax or free intra-peritoneal fluid. Conversely, a depressed left ventricular ejection fraction (LVEF) of 36% and an anterolateral akinesia were observed. ECG showed ST-segment elevation in anterolateral leads while ultrasensitive cardiac troponin I was 4580 ng/L (normal value < 45). Total body CT scanning revealed a sternal ( Fig. 1 panel A) and 9th to 11th ribs fractures of the right hemithorax. At that stage, AMI due to the blunt chest trauma was highly suspected and the patient was directly transferred to the cath-lab. After receiving low molecular weight heparin, ticagrelor loading dose and acetylsalicylic acid, coronary angiography (CA), performed via trans-radial approach, demonstrated a complete acute occlusion of the left anterior descending artery (LAD) ( Fig. 1 , panels B and C and Movie I in the online supplement data) and recruitment of collateral vessels originating from the right coronary artery (RCA) (Fig. 1 , panel D). Moreover, ventriculography disclosed anterolateral akinesia and an LVEF of 33% ( Movie II in the online data supplement). Despite repeated attempts, the reperfusion of the vessel resulted ineffective for the absence of a visible origin of its occlusion and both the probable collapse and diffuse spasm of the vessel after the trauma. Considering her young age, absence of comorbidities and bleeding events after the trauma, she was transferred to the cardiac surgery department where she received an off-pump coronary artery bypass grafting within 2 h from her first medical contact. Specifically, a left internal mammary artery graft to the LAD was performed without intra-operative complications. The patient was then transferred to the intensive care unit for 2 days and subsequently to the ward. After one month from the discharge, she was asymptomatic and her LVEF improved to 48%. Acute coronary artery occlusion, after blunt chest trauma is a rare life-threatening event that occurs in about 3% of patients with cardiac injuries [  ]. Moreover, it has been estimated that only 13% of these patients underwent coronary catheterization within 24 h from admission [  ]. The optimal therapeutic management of AMI due to blunt chest trauma is still matter of speculation. A mini-review of the literature, performed in PubMed on the occurrence and treatment of myocardial infarction after blunt chest trauma, revealed 24 case reports/series in English language (17 male and 7 women, mean age 43.6 ± 12.6 years) over the last 5 years. Of these, 3 patients (12.5%) were treated medically, 2 (8.3%) with CABG and one (4.1%) received systemic thrombolysis after a prolonged resuscitation. Urgent PCI was performed in 10 subjects (41.6%): 5 received a drug eluting stent (DES), 4 a bare metal stent (BMS) and in a case the implanted device was not specified. Among these subjects, thromboaspiration was performed only in two cases. Conversely, 8 (33.3%) patients received a delayed PCI (5 treated with a DES, one with BMS and one not specified) which was performed between 24 h to 15 days after trauma. This strategy was mainly adopted to avoid serious or fatal hemorrhagic complications (potentially due to anticoagulation for PCI and subsequent dual antiplatelet therapy -DAPT-) in those patients who firstly required a trauma-related surgery. The possibility of coronary artery injury should be considered in all patients with chest pain after a blunt chest trauma. Since this condition could be not suspected or undiagnosed, we propose that an interventional cardiologist should be always included as “first line members” in the trauma Team, which usually perform the primary survey at admission, in case of severe anterior chest trauma and especially when the preliminary findings suggest a possible heart involvement. Prompt rather than delayed catheterization might be a rapid answer to address patients to percutaneous or surgical interventions.

    Source:

    Cardiovascular Revascularization Medicine, 2018-10-01, Volume 19, Issue 7, Pages 810-811, Copyright © 2018 Elsevier Inc.

     

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