Interact CardioVasc Thorac Surg 2009;9:537-539. doi:10.1510/icvts.2009.207001
© 2009 European Association of Cardio-Thoracic Surgery
Spontaneous coronary artery rupture in a young patient: a rare diagnosis for cardiac tamponade
Bishwo M.S. Shresthaa,*,
Christian Hamilton-Craigb,
David Plattsb and
Andrew Clarkea
a Division of Cardiothoracic Surgery, Prince Charles Hospital, Rode Road, Chermside, QLD 4032, Brisbane, Australia
b Department of Cardiology, Prince Charles Hospital, Brisbane, Australia
Received 9 March 2009;
received in revised form 4 May 2009;
accepted 5 May 2009
*Corresponding author. Tel.: +61 7 31394000; fax: +61 7 31394651.
E-mail address: bishwo_shrestha{at}health.qld.gov.au (B.M.S. Shrestha).
 |
Abstract
|
|---|
We report a case of spontaneous coronary artery rupture (SCAR) in a 43-year-old male who presented with symptoms of sudden onset of chest pain and hemodynamic collapse. There were no abnormal electrocardiogram changes and serum troponin was not detected. Acute aortic dissection was suspected but urgent contrast computed tomography (CT) showed a large pericardial effusion with cardiac tamponade. This was later confirmed on trans-oesophageal echocardiogram. The SCAR was seen intra-operatively as an isolated perforation of the posterior descending artery. The patient was successfully managed with direct repair under cardiopulmonary bypass. Postoperative multi-detector dual-source 64-slice CT coronary angiography revealed normal coronary arteries with absence of atherosclerotic plaque in all coronary arterial segments. It is concluded that, though rare, a differential diagnosis of SCAR should be considered in cases of acute chest pain with cardiac tamponade in adult patients of all ages.
Key Words: Coronary disease; Coronary artery rupture; Cardiac tamponade
|
1. Introduction
|
|---|
Spontaneous coronary artery rupture (SCAR) is a rare occurrence and there are <12 cases reported in the literature [1–6]. The etiology for SCAR was reported as atherosclerotic disease [1–3, 6], aneurysm [4], trauma [5], or localized infection [7]. However, SCAR without any underlying disease in a young and healthy patient is undescribed. We report the first case of SCAR in a 43-year-old previously healthy male with no past evidence of atherosclerotic disease.
|
2. Case presentation
|
|---|
A 43-year-male manual worker, while taking a shower in the morning, had a sudden onset of severe central chest pain associated with profound diaphoresis, nausea and vomiting. He called the ambulance and was transferred to his local hospital.
His past history revealed indirect inguinal hernia repair and presentations to the hospital for minor work-related trauma. He was never diagnosed to have coronary artery disease, hypertension or diabetes. He had smoked 20–30 cigarettes a day for 15 years, stopping 2 years prior to presentation. He denied any family history of ischemic heart disease.
At presentation in the emergency department, he was found to be acutely unwell, hypotensive with systolic blood pressure of 65 mmHg, pulse rate of 100 per min, respiratory rate of 28 per min, with significant jugular venous distension. No clinical abnormality was found on examination of his chest and abdomen. With a provisional diagnosis of acute coronary syndrome and differential diagnosis of acute type A aortic dissection, he was urgently investigated. The 12 lead electrocardiogram (ECG) and cardiac enzymes were normal with no ischemic changes. A contrast computed tomography (CT)-scan of the chest excluded aortic dissection but revealed a large pericardial effusion (Fig. 1a). The patient was referred for urgent surgery and intra-operative trans-oesophageal echocardiogram (TOE) due to progressively unstable hemodynamics. Intra-operative TOE confirmed the diagnosis of a large pericardial effusion with features of tamponade, and no evidence of myocardial regional wall motion abnormality, valvular or aortic pathology. He underwent urgent median sternotomy, and on opening the pericardium approximately 600 ml of fresh dark blood was evacuated. The intra-operative inspection revealed an isolated perforation in the middle part of an otherwise normally surfaced posterior descending artery (PDA) with continuous spurting of blood (Fig. 2), confirming the diagnosis of SCAR. The coronary perforation was 0.8 mm in size with a ragged edge. Coronary bypass grafting was not performed as on intra-operative local examination of the coronary artery there was no luminal stenosis, and therefore the risk of subsequent graft failure would have been high. The rupture site was repaired successfully with a small venous patch and pericardial pledgetted sutures under cardiopulmonary bypass and cardioplegic arrest. The venous patch was used to prevent post-repair coronary stenosis. Serum lipid profile of the patient was at upper limits of normal (total cholesterol 6.2 mmol/l). He was discharged on the tenth postoperative day, on medical therapy consisting of a statin.
View larger version (87K):
[in this window]
[in a new window]
|
Fig. 1. (a) Coronal non-gated computed tomography of the chest on arrival in the emergency department, demonstrating large pericardial effusion. (b) 64-slice dual-source CT coronary angiogram curved multi-planar reformat of the right coronary artery and posterior descending branch, showing absence of atherosclerotic plaque.
|
|
View larger version (87K):
[in this window]
[in a new window]
|
Fig. 2. Intra-operative photo: spontaneous coronary artery rupture (SCAR) of posterior descending branch of the coronary artery with spurting of fresh arterial blood from the surface of the heart.
|
|
Multi-disciplinary discussion among interventional cardiology, cardiac radiology and cardiothoracic surgery was undertaken to investigate the underlying etiology of SCAR in this patient. Invasive coronary angiography was thought unlikely to reveal luminal stenosis given the intra-operative arterial findings. Intravascular ultrasound and optical coherence tomography was considered; however, there was reluctance to pass instrumentation down an artery which had recently spontaneously ruptured, with unknown risk of recurrence. Thus, at 6 week postoperative period, a non-invasive assessment by multi-detector 64-slice dual-source CT of the coronary arterial tree was performed (Siemens Somatom definition, Erlangen, Germany). The multi-planar curved reconstruction of the CT angiogram revealed absence of atherosclerotic disease in the coronary tree (Fig. 1b).
|
3. Discussion
|
|---|
The occurrence of spontaneous coronary artery dissection (SCAD) is more common than SCAR as reported in the literature [8, 9]. In recent years, with the increase in radiological coronary interventions, the occurrences of coronary artery rupture appears to be increasing [8–10]. There are only few case reports of a primary SCAR [1, 2, 6]. Excluding the patient with post-blunt trauma SCAR [5], the age of all reported patients with SCAR were above 50 years. This is the first case report of primary SCAR in a young and healthy male without previous history of atherosclerotic disease.
In the majority of reported cases of SCAR, the patient presented with clinical symptoms suggestive of acute coronary syndrome or acute aortic dissection. Chest X-ray, CT-scan of chest, ECG, echocardiogram and cardiac enzyme were the most commonly used investigations for the diagnosis. In less than one-third of reported cases there were some ECG abnormalities and positive cardiac biomarkers, but invariably in all case reports the patients were diagnosed to have large pericardial effusion and the diagnosis of SCAR was overlooked. Pre- or postoperative coronary angiogram failed to show local coronary pathology in most of the cases and SCAR was diagnosed intra-operatively. There was only one post-mortem histopathology confirmation of SCAR [3].
With such a rare condition, it is difficult to establish any etiological pattern for the occurrence of SCAR. The possible etiologies for the occurrence of SCAR include external rupture of localized atheromatous plaque ulcer which also could be a nidus for SCAD. Other localized coronary pathology, such as aneurysm, inflammatory processes or localized trauma should also be taken into consideration [4, 5, 7]. According to Ellis' classification [9], the SCAR in this case can be classified as type III, which is associated with a high rate of cardiac tamponade and need for urgent bypass surgery in 63%, and mortality rate of 19%. Early diagnosis and emergent treatment is essential for a successful outcome of SCAR. There are various modalities of treatment available depending upon clinical presentation of SCAR, such as use of covered stent, pericardial patch with glue, venous patch repair, ligation with bypass grafting, and direct suture repair.
|
4. Conclusion
|
|---|
We conclude that, although rare, SCAR should be considered as a differential diagnosis in adult patients of all ages with acute chest pain and cardiac tamponade. Early diagnosis of SCAR would lead to urgent surgical or non-surgical (coronary stenting) treatment and prevent fatal outcome of the disease.
|
References
|
|---|
- Butz T, Lamp B, Figura T, Faber L, Esdorn H, Wiemer M, Kleikamp G, Horstkotte D. Images in cardiovascular medicine. Pericardial effusion with beginning cardiac tamponade caused by a spontaneous coronary artery rupture. Circulation 2007;116:383–384.[CrossRef]
- Kaljusto ML, Koldsland S, Vengen AO, Woldbaek PR, Tonnessen T. Cardiac tamponade caused by acute spontaneous coronary artery rupture. J Cardiac Surg 2006;21:301–303.[CrossRef][Medline]
- Burke AP, Farb A, Malcom GT, Liang YH, Smialek JE, Virmani R. Plaque rupture and sudden death related to exertion in men with coronary artery disease. J Am Med Assoc 1999;281:921–926.[Abstract/Free Full Text]
- Gunduz H, Akdemir R, Binak E, Tamer A, Uyan C. Spontaneous rupture of a coronary artery aneurysm: a case report and review of the litera- ture. Jpn Heart J 2004;45:331–336.[CrossRef][Medline]
- Dueholm S, Fabrin J. Isolated coronary artery rupture following blunt chest trauma: a case report. Scand J Thorac Cardiovasc Surg 1986;20:183–184.[Medline]
- Motoyoshi N, Komatsu T, Moizumi Y, Tabayashi K. Spontaneous rupture of coronary artery. Eur J Cardiothoracic Surg 2002;22:470–471.[Abstract/Free Full Text]
- Fan CC, Andersen BR, Sahgal. Isolated myocardial abscess coronary artery rupture with fatal hemopericardium. Arch Pathol Lab Med 1994;118:1023–1025.[Medline]
- Celik SK, Sagcan A, Altintig A, Yuksel M, Akin M, Kultursay H. Primary spontaneous coronary artery dissection in atherosclerotic patients. Eur J Cardiothoracic Surg 2001;20:573–576.[Abstract/Free Full Text]
- Ellis SG, Ajluni S, Arnold AZ. Increased coronary perforation in the new device era. Incidence, classification, management, and outcome. Circulation 1994;90:2725–2730.[Abstract/Free Full Text]
- Lansky AJ, Yang Y, Khan Y, Costa RA, Pietras C, Tsuchiya Y, Cristea E, Collins M, Mehran R, Dangas GD, Moses JW, Leon MB, Stone GW. Treatment of coronary artery perforations complicating percutaneous coronary intervention with a polytetrafluoroethylene-covered stent graft. Am J Cardiol 2006;98:370–374.[CrossRef][Medline]
|
|
Top
Abstract
1. Introduction