Eur J Cardiothorac Surg 2007;31:320-321. doi:10.1016/j.ejcts.2006.11.019
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved
Mediastinal hematoma and left main dissection following blunt chest trauma
Yu-Yun Nan,
Jen-Ping Chang,
Ming-Shian Lu,
Chiung-Lun Kao*
Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital at Chiayi, Chang Gung Institute of Technology, Taiwan, ROC
Received 13 August 2006;
received in revised form 31 October 2006;
accepted 14 November 2006.
* Corresponding author. Address: Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital at Chiayi, 6 Sec. West, Chia Pu Road, Putzu City, Chiayi Hsien, Taiwan 613, ROC. Tel.: +886 5 3621000; fax: +886 5 3623002. (Email: sa11421{at}adm.cgmh.org.tw).
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Abstract
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A 40-year-old man sustained blunt chest trauma resulting in sternal fracture, mediastinal hematoma, and dissection of the left main coronary artery. Because of associated injury, the coronary angiogram was performed 7 days after the accident and off-pump coronary bypass surgery was performed immediately. Two months later, follow-up angiogram revealed completely healed left main dissection. The patient continues to do well 4 months postoperatively.
Key Words: Coronary artery disease • Nonpenetrating wounds • Heart injuries
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1. Introduction
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Traumatic coronary artery injury with myocardial infarction is a rare but potentially fatal complication. It is usually associated with multiple organs trauma. Once the diagnosis is delayed, ventricular function impairment or even death could be the result. We describe a patient who sustained blunt chest trauma that resulted in mediastinal hematoma and acute dissection of the left main coronary artery.
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2. Case report
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A 40-year-old man, an unrestrained driver, was involved in a steer-wheel injury. He was brought to our hospital with stable vital signs but complained of chest pain. Physical examination revealed mild respiratory distress and sternal fracture with flail anterior chest. The chest roentgenogram revealed widening of the superior mediastinum, and the chest computed tomographic scan revealed retrosternal hematoma and multiple ribs fractures (Fig. 1
). Electrocardiogram (ECG) demonstrated ST-segment elevations through leads V1–V3 suggestive of acute anterior myocardial infarction. Cardiac enzymes were elevated (myocardial band enzymes of creatine phosphokinase, 682.1 ng/ml; troponin I, 31.5 ng/ml). Two-dimensional echocardiography demonstrated impaired left ventricular function (ejection fraction, 34%) and hypokinesia of anterior and anterolateral walls. Although coronary angiogram was mandatory for differentiating myocardial contusion from coronary injury, emergent coronary angiography was deferred due to mediastinal hematoma and relative stable hemodynamic status. Because of the respiratory distress secondary to the flail chest, he needed 6 days of ventilator support during the ongoing admission.
The cardiac catheterization performed after weaning off the ventilator revealed distal left main coronary artery dissection with proximal left anterior descending (LAD) artery involvement (Fig. 2
). Unfortunately, cardiovascular collapse developed during the procedures; therefore, he was brought to the operating room with intra-aortic balloon pumping for emergent coronary artery bypass grafting.
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Fig. 2. The coronary angiography demonstrated dissection of left main trunk with left anterior descending artery involvement.
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During the sternotomy, fractured sterno–manubrial junction and resolved mediastinal hematoma were noted. The left internal thoracic artery (LITA) was not harvested due to retrosternal hematoma around the internal thoracic arteries and possibly compromised conduit quality. The operation was carried out by off-pump coronary artery bypass (OPCAB) with reversed saphenous bypass to LAD and left circumflex arteries. The recovery was uneventful, and he was discharged on the 7th postoperative day. The coronary angiography performed 2 months later showed that the left main dissection was completely healed with left ventricular ejection fraction of 43%. The patient continues to do well 4 months after the operation.
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3. Discussion
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Sternal fractures may result in mediastinal hematoma secondary to the fracture sites oozing. The hematoma resolves spontaneously in 2–9 weeks, and the clinical course is benign [1]. The differential diagnosis between cardiac contusion and traumatic myocardial infarction secondary to the coronary injury is difficult. In both situations, patients may present with abnormal ECG and elevated cardiac enzymes. To make a definite diagnosis, coronary angiography is mandatory. Traumatic left main stem lesions seem to be exceptionally rare and only a few reports were found in the literature [2].
Management of patients with traumatic myocardial infarction secondary to the coronary injury remains controversial due to its rare incidence and its frequent association with other traumatic injuries [2–5]. In the report from Harada et al. [4], the diagnostic coronary angiography is deferred like in our patient, which, resulted in incomplete restoration of the left ventricular function. Although successful percutaneous intervention has been reported, controversies still exist considering the risk regarding the anatomical feature of the lesion [1,5].
The OPCAB has been getting popular with promising mid-term outcomes and is found to be the most suitable for high-risk patients [6]. In fact, OPCAB with LITA to LAD has been successfully applied in a patient with traumatic LAD dissection associated with multiple injuries [5].
For our patient, the saphenous vein graft is selected as the conduit for OPCAB because of possibly compromised LITA integrity secondary to the sternal fracture. In addition, the natural history of traumatic coronary injury is reported to be healed completely within 6 months just like in our patient, and this observation further justifies the use of vein graft as the conduit in patients who suffer from traumatic coronary injuries [7]. If angiography of both ITAs could be performed during coronary catheterization to ensure the patency of the ITAs, one of the ITAs could be used as a conduit in young patients.
In conclusion, blunt chest trauma may cause myocardial infarction secondary to coronary injury. This unusual catastrophic situation can be followed by subsequent ventricular dysfunction if not managed promptly. High degree of suspicion with early reperfusion therapy should be pivotal.
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References
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- Attar S, Ayella RJ, McLaughlin JS. The widened mediastinum in trauma. Ann Thorac Surg 1972;13:435-449.[Medline]
- Goktekin O, Unalir A, Gorenek B, Kudaiberdieva G, Cavusoglu Y, Melek M, Aslan R, Timuralp B. Traumatic ooclusion of left main coronary caused by blunt chest trauma. J Invasive Cardiol 2002;14:463-465.[Medline]
- Fu M, Wu CJ, Hsieh MJ. Coronary dissection and myocardial infarction following blunt chest trauma. J Formosan Med Assoc 1999;98:136-140.[Medline]
- Harada H, Honma Y, Hachiro Y, Mawatari T, Abe T. Traumatic coronary artery dissection. Ann Thorac Surg 2002;74:236-237.[Abstract/Free Full Text]
- Korach A, Hunter CT, Lazar HL, Shemin RJ, Shapira OM. OPCAB for acute LAD dissection due to blunt chest trauma. Ann Thorac Surg 2006;82:312-314.[Abstract/Free Full Text]
- Al-Ruzzeh S, Nakamura K, Athanasiou T, Modine T, George S, Yacoub M, Ilsley C, Amrani M. Does off-pump coronary 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]
- Kohli S, Saperia GM, Waksmonski CA, Pezzella S, Singh JB. Coronary artery dissection secondary to blunt chest trauma. Catheter Cardiovasc Diagn 1988;15:179-183.[Medline]
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Abstract
1. Introduction
