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Coronary artery dissection after blunt trauma without abnormal electrocardiogram findings
American Journal of Emergency Medicine xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Coronary artery dissection after blunt trauma without abnormal electrocardiogram findings☆,☆☆,★,★★ Abstract Coronary artery dissection after blunt trauma has rarely been reported, and all cases reported thus far have shown abnormal electrocardiogram (ECG) findings. We report a case of left main coronary artery dissection in the absence of abnormal ECG findings. This case suggests that coronary artery dissections should be considered in post–blunt trauma cases, even if patients present no laterality of blood pressure or present with normal findings on ECG and chest radiographs. In addition, physicians should follow up these patients closely before surgery. Traumatic coronary artery dissection after blunt chest trauma is extremely rare [1] and is usually associated with major trauma. The diagnosis is often delayed, and some cases are only diagnosed postmortem [2]. In addition, left main coronary artery dissection is even rarer [3]. We report a patient with acute left main coronary artery dissection after blunt trauma, which did not show any abnormalities on electrocardiogram (ECG). A healthy, 41-year-old man was admitted to the emergency department for left forearm pain after an accident. While riding a motorcycle on a rural highway, he was hit by a light motor vehicle. Upon admission, he was alert and had stable vital signs, except that his oxygen saturation was 90% despite receiving 100% oxygen, and he did not demonstrate laterality of blood pressure. Physical examinations revealed moderate tenderness and swelling of the right forearm, but no chest pain. Ultrasonography indicated pericardial effusion, without evidence of cardiac tamponade. Chest radiography indicated a left pneumothorax, without mediastinal enlargement; his ECG was normal. An axial-enhanced chest computed tomography showed pericardial effusion, periaortic hematoma, and bilateral pleural effusions (Fig. 1). The patient was transferred to the operating room; there were no changes in the patient's ECG prior to his undergoing
☆ Financial disclosure: None. ☆☆ Conflict of interest: There are no conflicts of interest. ★ Consent: Written informed consent was obtained from the patient for publication of this case report and the accompanying images. ★★ Contributions: Y.K., M.T., F.I., Y.K., and K.S. contributed to patient management. Y.K. and R.I. drafted the initial manuscript and performed the study screenings independently. N.Y. and K.S. critically reviewed the manuscript. All authors have provided written consent for publication.
a cardiopulmonary bypass. Intraoperative findings included a pseudoaneurysm at the lesser curvature and a torn tunica media surrounding the left coronary inflow orifice (Fig. 2). He underwent aortic root replacement and coronary artery bypass grafting of the left main trunk. He was discharged 4 weeks after surgery, as there were no complications. This case shows that left coronary artery dissection should be considered in similar cases of post–blunt chest trauma, even in case of normal ECG findings. To our knowledge, 24 cases of coronary artery dissection after blunt chest trauma have been reported in the literature [4,5]; all these cases showed abnormal ECG findings. In these types of injuries, dissections most often occur in the left anterior descending artery but may also occur in the right coronary artery and, rarely, in the left main coronary artery [5,6]. Identifying trauma-induced coronary artery dissection can be difficult [5]. There are no guidelines to assist the identification of patients at risk. Thus, physicians should consider coronary artery dissection after a blunt trauma, even if the patient has normal ECG findings and chest radiographs and does not display blood pressure laterality. Our case suggests that coronary artery dissections should be considered in post–blunt trauma, even if patients present no laterality of blood pressure or present with normal ECG findings and chest radiographs. In addition, physicians should follow up these patients closely before surgery.
Fig. 1. Enhanced chest computed tomography showing dissection of the ascending aorta, with pericardial effusion, periaortic hematoma, and bilateral pleural effusions. The arrow indicates the ascending aortic dissection.
0735-6757/$ – see front matter © 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Kawakami Y, et al, Coronary artery dissection after blunt trauma without abnormal electrocardiogram findings, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.02.046
2
Y. Kawakami et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx
Masahiro Tanji MD, PhD Department of Cardiovascular Surgery Ohta Nishinouchi Hospital, Koriyama Fukushima 963-8558, Japan Fumihito Ito MD Yoshibumi Kumada MD, PhD Department of Emergency and Critical Care Medicine Ohta Nishinouchi Hospital, Koriyama Fukushima 963-8558, Japan Shinji Matsuse MD, PhD Naoki Yahagi MD, PhD Department of Emergency and Critical Care Medicine The University of Tokyo Hospital Tokyo 113-8655, Japan Fig. 2. An intraoperative photograph showing the circumferentially dissected Valsalva sinus (arrow).
Kazuaki Shinohara MD, PhD Department of Emergency and Critical Care Medicine Ohta Nishinouchi Hospital, Koriyama Fukushima 963-8558, Japan
Acknowledgment We would like to thank Mrs Takako Sakamaki for her assistance. Yutaka Kawakami MD Department of Emergency and Critical Care Medicine Ohta Nishinouchi Hospital Koriyama Fukushima 963-8558, Japan Ryota Inokuchi MD Department of Emergency and Critical Care Medicine Ohta Nishinouchi Hospital Koriyama, Fukushima 963-8558, Japan Department of Emergency and Critical Care Medicine The University of Tokyo Hospital Tokyo 113-8655, Japan E-mail address: [email protected]
http://dx.doi.org/10.1016/j.ajem.2014.02.046 References [1] Carter Y, Meissner M, Bulger E, et al. Anatomical considerations in the surgical management of blunt thoracic aortic injury. J Vasc Surg 2001;34:628–33. [2] Korach A, Hunter CT, Lazar HL, Shemin RJ, Shapira OM. OPCAB for acute LAD dissection due to blunt chest trauma. Ann Thorac Surg 2006;82:312–4. [3] Li CH, Chiu TF, Chen JC. Extensive anterolateral myocardial infarction caused by left main coronary artery dissection after blunt chest trauma: a case report. Am J Emerg Med 2007;25:858.e3-5. [4] James MM, Verhofste M, Franklin C, Beilman G, Goldman C. Dissection of the left main coronary artery after blunt thoracic trauma: case report and literature review. World J Emerg Surg 2010;5:21. [5] Lobay KW, MacGougan CK. Traumatic coronary artery dissection: a case report and literature review. J Emerg Med 2012;43:e239–43. [6] Harada H, Honma Y, Hachiro Y, Mawatari T, Abe T. Traumatic coronary artery dissection. Ann Thorac Surg 2002;74:236–7.
Please cite this article as: Kawakami Y, et al, Coronary artery dissection after blunt trauma without abnormal electrocardiogram findings, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.02.046
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Coronary artery dissection after blunt trauma without abnormal electrocardiogram findings☆,☆☆,★,★★ Abstract Coronary artery dissection after blunt trauma has rarely been reported, and all cases reported thus far have shown abnormal electrocardiogram (ECG) findings. We report a case of left main coronary artery dissection in the absence of abnormal ECG findings. This case suggests that coronary artery dissections should be considered in post–blunt trauma cases, even if patients present no laterality of blood pressure or present with normal findings on ECG and chest radiographs. In addition, physicians should follow up these patients closely before surgery. Traumatic coronary artery dissection after blunt chest trauma is extremely rare [1] and is usually associated with major trauma. The diagnosis is often delayed, and some cases are only diagnosed postmortem [2]. In addition, left main coronary artery dissection is even rarer [3]. We report a patient with acute left main coronary artery dissection after blunt trauma, which did not show any abnormalities on electrocardiogram (ECG). A healthy, 41-year-old man was admitted to the emergency department for left forearm pain after an accident. While riding a motorcycle on a rural highway, he was hit by a light motor vehicle. Upon admission, he was alert and had stable vital signs, except that his oxygen saturation was 90% despite receiving 100% oxygen, and he did not demonstrate laterality of blood pressure. Physical examinations revealed moderate tenderness and swelling of the right forearm, but no chest pain. Ultrasonography indicated pericardial effusion, without evidence of cardiac tamponade. Chest radiography indicated a left pneumothorax, without mediastinal enlargement; his ECG was normal. An axial-enhanced chest computed tomography showed pericardial effusion, periaortic hematoma, and bilateral pleural effusions (Fig. 1). The patient was transferred to the operating room; there were no changes in the patient's ECG prior to his undergoing
☆ Financial disclosure: None. ☆☆ Conflict of interest: There are no conflicts of interest. ★ Consent: Written informed consent was obtained from the patient for publication of this case report and the accompanying images. ★★ Contributions: Y.K., M.T., F.I., Y.K., and K.S. contributed to patient management. Y.K. and R.I. drafted the initial manuscript and performed the study screenings independently. N.Y. and K.S. critically reviewed the manuscript. All authors have provided written consent for publication.
a cardiopulmonary bypass. Intraoperative findings included a pseudoaneurysm at the lesser curvature and a torn tunica media surrounding the left coronary inflow orifice (Fig. 2). He underwent aortic root replacement and coronary artery bypass grafting of the left main trunk. He was discharged 4 weeks after surgery, as there were no complications. This case shows that left coronary artery dissection should be considered in similar cases of post–blunt chest trauma, even in case of normal ECG findings. To our knowledge, 24 cases of coronary artery dissection after blunt chest trauma have been reported in the literature [4,5]; all these cases showed abnormal ECG findings. In these types of injuries, dissections most often occur in the left anterior descending artery but may also occur in the right coronary artery and, rarely, in the left main coronary artery [5,6]. Identifying trauma-induced coronary artery dissection can be difficult [5]. There are no guidelines to assist the identification of patients at risk. Thus, physicians should consider coronary artery dissection after a blunt trauma, even if the patient has normal ECG findings and chest radiographs and does not display blood pressure laterality. Our case suggests that coronary artery dissections should be considered in post–blunt trauma, even if patients present no laterality of blood pressure or present with normal ECG findings and chest radiographs. In addition, physicians should follow up these patients closely before surgery.
Fig. 1. Enhanced chest computed tomography showing dissection of the ascending aorta, with pericardial effusion, periaortic hematoma, and bilateral pleural effusions. The arrow indicates the ascending aortic dissection.
0735-6757/$ – see front matter © 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Kawakami Y, et al, Coronary artery dissection after blunt trauma without abnormal electrocardiogram findings, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.02.046
2
Y. Kawakami et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx
Masahiro Tanji MD, PhD Department of Cardiovascular Surgery Ohta Nishinouchi Hospital, Koriyama Fukushima 963-8558, Japan Fumihito Ito MD Yoshibumi Kumada MD, PhD Department of Emergency and Critical Care Medicine Ohta Nishinouchi Hospital, Koriyama Fukushima 963-8558, Japan Shinji Matsuse MD, PhD Naoki Yahagi MD, PhD Department of Emergency and Critical Care Medicine The University of Tokyo Hospital Tokyo 113-8655, Japan Fig. 2. An intraoperative photograph showing the circumferentially dissected Valsalva sinus (arrow).
Kazuaki Shinohara MD, PhD Department of Emergency and Critical Care Medicine Ohta Nishinouchi Hospital, Koriyama Fukushima 963-8558, Japan
Acknowledgment We would like to thank Mrs Takako Sakamaki for her assistance. Yutaka Kawakami MD Department of Emergency and Critical Care Medicine Ohta Nishinouchi Hospital Koriyama Fukushima 963-8558, Japan Ryota Inokuchi MD Department of Emergency and Critical Care Medicine Ohta Nishinouchi Hospital Koriyama, Fukushima 963-8558, Japan Department of Emergency and Critical Care Medicine The University of Tokyo Hospital Tokyo 113-8655, Japan E-mail address: [email protected]
http://dx.doi.org/10.1016/j.ajem.2014.02.046 References [1] Carter Y, Meissner M, Bulger E, et al. Anatomical considerations in the surgical management of blunt thoracic aortic injury. J Vasc Surg 2001;34:628–33. [2] Korach A, Hunter CT, Lazar HL, Shemin RJ, Shapira OM. OPCAB for acute LAD dissection due to blunt chest trauma. Ann Thorac Surg 2006;82:312–4. [3] Li CH, Chiu TF, Chen JC. Extensive anterolateral myocardial infarction caused by left main coronary artery dissection after blunt chest trauma: a case report. Am J Emerg Med 2007;25:858.e3-5. [4] James MM, Verhofste M, Franklin C, Beilman G, Goldman C. Dissection of the left main coronary artery after blunt thoracic trauma: case report and literature review. World J Emerg Surg 2010;5:21. [5] Lobay KW, MacGougan CK. Traumatic coronary artery dissection: a case report and literature review. J Emerg Med 2012;43:e239–43. [6] Harada H, Honma Y, Hachiro Y, Mawatari T, Abe T. Traumatic coronary artery dissection. Ann Thorac Surg 2002;74:236–7.
Please cite this article as: Kawakami Y, et al, Coronary artery dissection after blunt trauma without abnormal electrocardiogram findings, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.02.046