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Ann Thorac Surg 2006;82:312-314
© 2006 The Society of Thoracic Surgeons

Case report

OPCAB for Acute LAD Dissection Due to Blunt Chest Trauma

Amit Korach, MD, Curtis T. Hunter, MD, Harold L. Lazar, MD, Richard J. Shemin, MD, Oz M. Shapira, MD *

Department of Cardiothoracic Surgery, Boston Medical Center, Boston, Massachusetts

Accepted for publication September 22, 2005.

* Address correspondence to Dr Shapira, Department of Cardiothoracic Surgery, Suite B-402, Boston Medical Center, 88 E Newton St, Boston, MA 02118 (Email: oz.shapira{at}bmc.org).


   Abstract
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 Abstract
Introduction
 Comment
 References
 
A 40-year-old male pedestrian was hit by a truck and was admitted with multiple injuries including blunt chest trauma. Electrocardiogram revealed acute anterior ST-segment elevation and myocardial infarction. Coronary angiography demonstrated acute ostial left anterior descending coronary artery dissection. Due to extent and location, the lesion was not amenable for angioplasty. Multiple associated injuries and severely impaired coagulation studies directed us to perform emergency off-pump coronary artery bypass grafting.


   Introduction
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 Abstract
 Introduction
Comment
 References
 
Traumatic coronary artery dissection after blunt chest trauma is extremely rare [1]. It is usually associated with multiple organ trauma. The diagnosis is often delayed and some are only diagnosed postmortem. Treatment options include thrombolytic therapy, percutaneous intervention, and coronary artery bypass grafting [1–3]. We describe a patient with acute coronary artery dissection after blunt chest trauma who had off-pump coronary artery bypass grafting (OPCAB). We believe that this is the first report of OPCAB for traumatic coronary artery dissection.

A 40-year-old man was hit by a truck after stepping off a bus. His past medical history was significant for alcohol abuse with liver cirrhosis. Examination upon arrival revealed a Glasgow coma scale of 15, a heart rate of 118 beats/min, blood pressure at 160/80 mm Hg, room air saturation of 92%, and overt blunt facial and chest wall trauma. Laboratory data included hematocrit of 31%, platelet count of 54,000/µL, partial thromboplastin time of 57 seconds, and international normalized ratio of 1.6. Plain chest roentgenogram revealed right lower lobe infiltrate suggestive of bronchial aspiration and multiple rib fractures. Electrocardiogram (Fig 1A) demonstrated 4-mm ST-segment elevations in leads V1 to V4 suggestive of acute anterior-septal myocardial infarction. Echocardiography demonstrated a small amount of pericardial effusion with a markedly reduced left ventricular ejection fraction (25%) and severe hypokinesis of the septum and the anterior wall.


Figure 1
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  		Fig 1. Admission electrocardiogram (ECG) (panel A) showing ST elevation in leads V1–V4 suggestive of acute anterior-septal myocardial infarction. Postoperative ECG (panel B) showing complete resolution of the ischemic changes.

 
The patient was transferred immediately to the catheterization laboratory. Diagnostic coronary angiography revealed ostial left anterior descending coronary artery (LAD) dissection starting at the takeoff of the vessel from the left main and extending 2 cm distally. Other coronary arteries were free of disease (Fig 2). Percutaneous intervention was considered high risk because of the proximity of the lesion to the left main coronary artery. The patient was taken to the operating room for emergency coronary artery bypass grafting. Because of the patient's history of cirrhosis, multiple organ injuries, and severe coagulopathy, we elected to perform an OPCAB. Low-dose intravenous heparin (0.2 mg/kg) was administered with a target activated clotting time of 250 seconds, and an OPCAB left internal mammary artery to the LAD was performed. The operative course was uneventful. Postoperative electrocardiogram (Fig 1B) demonstrated complete resolution of the ST-segment elevation changes. The patient was discharged 4 weeks later due to other trauma-related problems. He had no OPCAB-related complications.


Figure 2
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  		Fig 2. Coronary angiography demonstrating acute ostial left anterior descending coronary artery (LAD) dissection (arrows). (Cx = circumflex.)

 

   Comment
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 Abstract
 Introduction
 Comment
References
 
Electrocardiographic changes in ST-T segment elevations after blunt chest trauma are not rare. Most commonly ST-T segment elevation changes represent myocardial contusion [1]. However, significant ST-T segment elevation changes may be caused by coronary artery spasm, thrombosis, dissection of the aorta with propagation to the coronary arteries, or coronary artery dissection [1].

Acute traumatic dissection of a coronary artery after blunt thoracic trauma is extremely rare [1–3]. The LAD is involved in the majority of the cases followed by the right, circumflex, and left main coronary arteries. Patients may present acutely with myocardial ischemia, or later with left ventricular dysfunction or coronary artery aneurysm [1–3]. The diagnosis is frequently missed or delayed, and at times it is achieved only at postmortem examination.

Several treatment approaches for acute coronary artery dissection after blunt chest trauma were previously described [1–3]. Percutaneous intervention was successfully performed with satisfactory early results [1]. Although percutaneous intervention mandates aggressive anti-platelet treatment, it is still an attractive approach in the setting of acute trauma because it affords rapid revascularization of the culprit vessel and is minimally invasive [1]. In our case percutaneous intervention was considered to be to high risk because of the anatomic features of the lesion.

Although on-pump coronary artery bypass grafting was successfully used in the past in this setting, it has significant disadvantages [2]. In the setting of acute multiple trauma, on-pump coronary artery bypass grafting carries a substantial risk for bleeding from the operation site as well as from injured organs due to the need for systemic anticoagulation using high-dose heparin, as well as cardiopulmonary bypass associated coagulopathy. Exposure to cardiopulmonary bypass in the setting of multiple traumas may aggravate organ dysfunction, particularly increasing the risk of pulmonary, renal, and neurologic complications.

Recently, OPCAB operations have being increasingly performed with promising short-term and mid-term clinical outcomes [4]. Avoiding the cardiopulmonary bypass has been shown to reduce postoperative coagulopathy and blood transfusions, renal complications, and possibly improve neurologic outcomes [5]. The OPCAB approach was indeed found to be most effective in high-risk patients [5]. It is because of these potential advantages that we selected the OPCAB left internal mammary artery to the LAD in our patient. We were able to use very small doses of heparin in a patient with already established coagulopathy, avoid global ischemia in the setting of acute myocardial contusion, and eliminate cardiopulmonary bypass induced adverse effects in a patient with multiple injuries, particularly head trauma and pulmonary contusion.

In conclusion, OPCAB operation is a safe and effective technique for the treatment of patients with acute dissection of a coronary artery after blunt chest trauma. Off-pump coronary artery bypass grafting should strongly be considered as the revascularization procedure of choice in this setting when percutaneous intervention is not feasible.


   References
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 Abstract
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 Comment
 References
 

  1. Ginzburg E, Dygert J, Parra-Davila E, Lynn M, Almedia J, Mayor M. Coronary artery stenting for occlusive dissection after blunt chest trauma J Trauma 1988;45:157-161.
  2. Boland J, Raymond L, Genevive T, Legrand V, Kulbertus H. Left main coronary artery dissection after mild chest trauma Chest 1988;93:213-214.[Abstract/Free Full Text]
  3. Kohli S, Saperia GM, Waksmonski CA, et al. Coronary artery dissection secondary to blunt chest trauma Cathet Cardiovasc Diagn 1988;15:179.[Medline]
  4. Sabik JF, Blackstone EH, Lytle BW, Houghtaling PL, Gillinov AM, Cosgrove DM. Equivalent midterm outcomes after off-pump and on-pump coronary surgery J Thorac Cardiovasc Surg 2004;127:142-148.[Abstract/Free Full Text]
  5. Al-Ruzzeh S, Nakamara K, Athanasiou T, et al. Does off-pump coronary artery bypass (OPCAB) surgery improve the outcome in high-risk patients? A comparative study of 1398 high-risk patients Eur J Cardiothorac Surg 2003;23:50-55.[Abstract/Free Full Text]



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This Article
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Amit Korach
Curtis T. Hunter
Harold L. Lazar
Richard J. Shemin
Oz M. Shapira
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Right arrow Coronary disease

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