A Case of Left Main Coronary Stenting for Acute Myocardial Infarction Complicated by Ascending Aortic Dissection

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1 증례 Korean Circulation J 2004;34(12): Case of Left Main Coronary Stenting for cute Myocardial Infarction Complicated by scending ortic Dissection Yong Seop Kwon, MD, Hyun Sang Lee, MD, Jae Kook Shin, MD, young Jin Chang, MD, Hyung Seop Kim, MD, Seung Chul Shin, MD, Jung Ho Heo, MD, Dong Heon Yang, MD, Hun Sik Park, MD, Yong Keun Cho, MD, Shung Chull Chae, MD, Jae Eun Jun, MD and Wee Hyun Park, MD Department of Internal Medicine, Kyungpook National University College of Medicine, Daegu, Korea STRCT We report here on a case of ascending aortic dissection combined with anterior myocardial infarction that was caused by a retrograde dissection into the left main coronary trunk and proximal left anterior descending artery. We successfully treated this with stenting of the left main coronary artery and proximal left anterior descending artery, and this allowed for the definitive surgical correction. Stenting a collapsed left main coronary artery can be lifesaving procedure and serve as a bridge to surgery. (Korean Circulation J 2004;34(12): ) KEY WORDS:ortic disease;dissection;myocardial infarction;coronary disease. Introduction Received:October 26, 2004 ccepted:november 1, 2004 Correspondence:Hun Sik Park, MD, Department of Internal Medicine, Kyungpook National University College of Medicine, 50 Samdeok-2ga, Jung-gu, Daegu , Korea Tel: , Fax: hspark@knu.ac.kr ortic dissection is caused by a circumferential tear or less frequently, it is caused by a transverse tear of the intima. It often occurs along the right lateral wall of the ascending aorta where the hydraulic shear stress is high. cute aortic dissection presents with the sudden onset of pain, which is often described as being very severe with a tearing sensation, and diaphoresisis associated with this condition. ortic regurgitation, bowel ischemia, hematuria, myocardial ischemia, and various neurologic findings due to carotid artery obstruction (hemiplegia and hemianesthesia) or spinal cord ischemia (paraplegia) have all been observed as complications resulting from the dissection occluding the major arteries. 1) Of these maladies, acute myocardial infarction by coronary artery dissection is a rare, but fatal complication of aortic dissection because this usually involves the left main coronary artery and the proximal right coronary artery. 2)3) In such a case, the only modality of treatment was operative correction of aortic dissection and coronary artery bypass graft surgery. However, great progress for the interventional skill of doctors has recently been displayed, and there has been the development of new stenting procedures and intravascular ultrasonography (IVUS). ccordingly, attempts are being made to treat left main coronary artery dissection by stent insertion and there are several reports showing successful results. 4-7) Yet, there has not been such report in Korea. We report here a successfully treated case of left main coronary artery dissection that was complicated by ascending aortic dissection. Case 41-year-old male visited the emergency room of a local hospital with a two-hour long chest pain. The pain felt like an excruciating ripping sensation through the 1210

2 Figure 1. The initial ECG showing the tall T wave on the precordial leads (). The follow up ECG showing the improved tall T wave on the precordial leads (). The follow up ECG showing the ST segment elevation on the I, avl and precordial leads (C). ECG: electrocardiogram. C C D Figure 2. t the initial phase of contrast injection, the left anterior oblique caudal view () and anteroposterior caudal view () showed the heterogenous filling defect in the proximal left anterior descending artery. Later, however, the left anterior oblique caudal view (C) and anteroposterior caudal view (D) showed no filling defect in the proximal left anterior descending artery. 1211

3 anterior chest radiating toward the back, and this was accompanied by cold sweating, nausea and vomiting. The 37. There were no specific findings on the physical examination. The results of laboratory tests, including cardiac blood pressure dropped to 90/60 mmhg with the patient displaying an altered mentality and shallow respiration. enzyme testing, were within the normal range except for a mild leukocytosis. The initial electrocardiogram (ECG) fter endotracheal intubation, he was transferred to our hospital. showed a tall T wave at the V2-6 precordial lead. There was no elevated ST segment (Figure 1). ntiplatelet He was a 20-pack-year smoker without any specific comorbidity. His elder brother died suddenly at the age of agent and heparin were administered under the impression of acute myocardial infarction. fter an hour, follow-up C D Figure 3. fter stenting the proximal left anterior descending artery, IVUS showed malposition of the stent (). The large false lumen compromising the true lumen and dissection flap (arrow) in the left main coronary artery (). fter left main coronary artery stenting, IVUS showed a residual false lumen (arrow) at the left main coronary artery (C). IVUS showed the membranous structure (arrow) in the ascending aorta near to the left main coronary artery (D). IVUS: intravascular ultrasonography. Figure 4. fter stenting the proximal left anterior descending artery, the coronary angiogram shows the compromised left main and left circumflex artery flows (arrow) (). fter left main coronary artery stenting, the coronary angiogram shows the recovered blood flow () Korean Circulation J 2004;34(12):

4 ECG showed a resolution of the tall T wave (Figure 1), but the chest pain persisted. To differentiate acute myocardial infarction from other possible causes such as aortic dissection, echocardiography and computed tomography (CT) were planned. t that time, he again complained severe chest pain and the follow-up ECG showed ST segment elevation at the I, avl and precordial leads (Figure 1C). The echocardiography showed hypokinesia of the interventricular and the anterior wall of the left ventricle. On the follow up laboratory study, the level of the cardiac enzymes was elevated (CKM: 224 ng/ml). So we dia-gnosed the patient as having ST-elevation myocardial infarction because of the typical changes on the ECG and echocardiography. CT was skipped and the Figure 5. The computed tomography imaging showing dissection of the ascending aorta and descending aorta. The left main and proximal left anterior descending artery show good patency after stenting. patient was moved to the cardiac catheterization room for primary coronary intervention. Right coronary angiography (CG) showed no abnormality except for a mild luminal narrowing at the ostium of the right coronary artery. Left CG showed an inhomogenous filling defect, which was probably due to external compression (Figure 2, ). The arterial lumen appeared to be expanded slightly during contrast injection (Figure 2C, D). During CG, the coronary artery lumen was compromised again and ventricular fibrillations requiring DC cardioversion occurred several times. alloon angioplasty (Scimed, mm) was done at 6 atmospheres for 30 seconds on the proximal left anterior descending artery. fter this, a stent was inserted (3.5 9 mm, 10 atmospheres for 20 seconds). Following this, IVUS was performed to find out the exact pathophysiology. pposition of stent was poor in the proximal left anterior descending artery (Figure 3). large false lumen and dissection flap compressing the true lumen were noted in the left main coronary artery (Figure 3). With retraction of the guiding catheter to the aorta, we found that the left main coronary artery was compressed. The blood flow was impaired not only in the left anterior descending artery, but also in the left circumflex artery (Figure 4). The blood flow was restored by an immediate stenting in the left main coronary artery ( mm, 12 atmospheres for 20 seconds, Figure 4). On the followup IVUS, the true lumen was patent, but the false lumen still remained (Figure 3C). Membranous structure that seemed to be a dissection flap was seen at the ascending aorta just outside the left main coronary artery (Figure 3D). This lesion extended to the left main coro- C Figure 6. Follow up coronary angiogram shows no significant stenosis in the left anterior oblique caudal view () and anteroposterior caudal view (). Follow up IVUS shows the intact stent and the residual false lumen (arrow) (C). IVUS: intravascular ultrasonography. 1213

5 nary artery and the proximal left anterior descending artery. Emergency chest CT showed the ascending aortic dissection (Figure 5). Upon operating, a large hematoma in the false lumen was found to be compressing the ascending aorta and coronary artery. Glue aortoplasty and aortic valve resuspension were then performed in a timely fashion. Five days after the operation, the patient was weaned from the mechanical ventilator and he was discharged without any specific complication. Restenosis was not present in the inserted stent on the follow-up CG performed at the 19th month after the operation (Figure 6, ). No intimal proliferation was noted in the IVUS, but the false lumen in the left main coronary artery and left anterior descending artery persistently remained (Figure 6C). The echocardiography showed marked improvement for the left ventricular wall motion and systolic function. Discussion cute myocardial infarction occurs in 1-2% of patients with dissection of the ascending aorta, and this happens because of compression of the coronary ostia by hematoma or occlusion by an intimal flap. 2) The dissection more often affects the right coronary artery than the left, and this explains why these myocardial infarctions tend to be inferior in location. 8)9) In case of patients presenting with acute chest pain and showing ST segment elevation on the electrocardiogram, treatment is often done by primary coronary intervention or thrombolytic therapy due to the clinical impression that the patient is only suffering from acute myocardial infarction. 10) In case of aortic dissection, however, thrombolytic therapy is contraindicated. Our patient was a case of myocardial infarction resulting from left main coronary artery dissection that was complicated by aortic dissection. If thrombolytic therapy had been applied, the condition of the patient might have fatally deteriorated. There have been a few reports on left main coronary artery dissection complicated by aortic dissection. Most of the cases resulted in a high mortality rate due to the low cardiac output from an extensive anterior myocardial infarction. Pego-Fernandes et al 11) analyzed 11 patients having 1214 aortic dissection that involved the right coronary artery. They underwent surgical treatment with a aortic graft and coronary artery bypass graft, and 27.3% of these cases displayed postoperative mortality. Neri et al 12) studied 34 cases that were treated with operation for aortic dissection involving the coronary ostia, and they reporting a 20% rate of in-hospital mortality. Kawada et al 13) studied the predictors of postoperative mortality in the 88 cases of ascending aortic dissection. They concluded that the preoperative complications from coronary dissection were the most important predictors of early postoperative mortality. Kawahito et al 14) also reviewed the surgical results and the mechanism of malperfusion in a group of 12 patients with coronary malperfusion caused by aortic dissection. They reported a 33.3% rate of mortality, and they insisted on the necessity of aggressive coronary revascularization and early aortic repair to salvage these critically ill patients. Recently, there have been reports of attempts to maintain the coronary artery flow through stent insertion prior to definitive surgical repair. arabas et al 4) have reported a case of emergency left main direct stenting that was used as a bridge to surgery in a patient with hemodynamic instability due to occlusion of the left main coronary artery; this occlusion was due to external compression caused by an intamural hematoma stemming from aortic dissection. In addition, Ikari et al, 5) Ohara et al, 6) and Cardozo et al 7) have also reported on treating cases of acute myocardial infarction associated with aortic dissection by stenting the left main coronary artery and/or the other coronary arteries as well. In this case, too, by promptly maintaining adequate myocardial blood flow, extensive myocardial damage was avoided. ccordingly, this treatment was believed to have reduced the pre- and post operative complications. dditionally, early stenting was considered to improve the patient s critical state and to have played a role as a bridge to definitive surgical management. This stenting procedure was also believed to have contributed to reducing the patient s risk of mortality. In summary, left main coronary artery dissection combined with aortic dissection is a rare but fatal complication of aortic dissection; this condition has a high mortality rate and it usually requires emergency surgical manage- Korean Circulation J 2004;34(12):

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