A STEMI WITH BAGGAGE
INTRODUCTION
Myocardial infarction with concomitant aortic dissection has a poor prognosis. A prompt, accurate diagnosis and management are fundamentals to survival since aortic dissection can be the etiology of a myocardial infarction and anticoagulation or thrombolytic treatment can result in catastrophic results.
We report a case of a 59-years-old male who presented to the Emergency Department with signs and symptoms of myocardial infarction (MI) and was found having concomitantly DeBakey type 1 aortic dissection (AD). The patient underwent a cardiac catheterization where his right coronary artery was maintained open and was transferred for a successful surgery of his aortic dissection.
TEACHING POINTS
The incenting event in aortic dissection is a tear in the aortic intima. AD and MI can coexist as a dissecting membrane can have retrograde propagation and may extend into a coronary ostium.
20% of patients with type A dissection have ECG evidence of acute ischemia or AMI.
ST Elevation in II, III and AVF suggests inferior wall infarction and right sided EKG leads should be performed to evaluate for right ventricular infarction.
Patient with suspected aortic dissection and EKG evidence of ischemia must undergo diagnostic imaging before thrombolytic .
CASE PRESENTATION
The patient is a 59-years-old male with no significant past medical history who came to the ED one hour after he developed a sudden onset, substernal and pressure-like chest pain radiating to the left arm. On admission, vitals were BP 99/46, HR 65, RR 16, T 37.1 and SaO2 91%. Physical exam was unremarkable. Given his type I respiratory failure, he was intubated. An EKG showed ST Elevation on II, III, AVF leads. Cardiac cath showed a type 1 aortic dissection and a severe aortic insufficiency. The right coronary artery was also noted to have a dissecting lawyer of 1cm.
The laboratory tests revealed a normal serum troponin T, the CBC count and BMP were unremarkable. Chest Xray was unrevealing and transthoracic echocardiography showed an ascending aortic dissection.
The patient was transferred to the OR where he had a PCI with DES in his RCA which got opened with the contrast. 3 hours later, he underwent an emergent surgical repair of his dissection and an aortic valve replacement with a composite biologic valve Hemashield conduit with a 25 mm Magna Ease Edwards valve and Hemashield graft.
He tolerated very well the procedure. However, after the surgery, he had a brief cardiac arrest requiring CPR resuscitation. The patient recovers successfully, gradually improved and was discharged 12 days later..
DISCUSSION
AD is the most common catastrophe of the aorta. The 2week mortality rate approaches 75% in patients with undiagnosed ascending AD. One of the serious complications of type A aortic dissection is coronary
malperfusion, which can be rarely complicated with acute myocardial function in 1% to 2% of the cases.
In a retrospective analysis, Hirata et al reported cases of aortic dissection associated by EKG signs of myocardial ischemia. It is fundamental to be aware of concomitant morbidities and for our patient, he just had symptoms of MI, not of AD. Therefore, not all STEMI are AMI only.
Treatment of a MI with AD is very challenging. Cannesson et al found that anticoagulation and thrombolysis double hemorrhagic complications and mortality and can result in mortality ranges from 69% to 100%. In our case, no thrombolytics were given before the intervention.
Treatment options include open replacement of the damaged section of the aorta with reimplantation of arteries with or without valve replacement depending upon the location and extent of the AD. For our patient, he was stabilized first by stenting his RCA then aortic dissection surgery with valve replacement
CONCLUSION
AD is the most common life-threatening disorder affecting the aorta and can be associated with inferior wall MI. Therefore, an urgent cardiac catheterization is always required to rule out coronary malperfusion.
It is fundamental to distinguish acute MI, for which thrombolytic therapy may be life saving, from AD, in which thrombolytic therapy may be fatal.
Even with the current Door to Balloon standards for STEMI (90 minutes), it is essential to be vigilant with the differentials for AMI even with STEMI.
Garly Rushler Saint Croix