Presenter: In Sook Kang
Operator: Wook Bum Pyun
Mokdong Hospital Cardiovascular center, Ewha Womans University
School of Medicine,
Medicine Seoul,
Seoul Korea
B k
Background
d
• Acute type A aortic dissection (AAAD) is lethal
condition and definitive therapy is emergency
surgery.
• Overall surgical mortality of AAAD is still high as
p
y in who aged
g 70 or over and upto
p
27.3% especially
30% in whom hypotensive.
• One of the rare,
rare but life
life-threatening
threatening complication is
acute myocardial infarction
Myocardial infarction with AAAD
• Direction extension of dissection or external
compression by the hematoma
• Incidence
id
; about
b
5-11%
• RCA is more often affected than the left
• Poor outcome: pre-op cardiac arrest, LCA territory
ischemia.
• Early revascularization by stenting is effective in
preventing postoperative low cardiac output
syndrome
Imoto et al.
al European Journal of Cardio-Thoracic
Cardio Thoracic Surgery (2013) 1–7
1 7
Case
C
•
•
•
•
•
77 yo male
C.C: tearing chest pain; ongoing for 30 min
pHx ; hypertension
hypertension, atrial fibrillation
Ex-smoker
Blood pressure of 80/50 mm Hg, heart rate
of 107 beats/min
I iti l EKG
Initial
ST-segment depression in leads of V3-V6, II, III and aVF.
Chest X ray
Portable chest AP
cardiomegaly with pulmonary edema
chest PA, 6month ago
• Primary PCI was planned due to ongoing
ischemic pain with cardiogenic shock.
• Heparin
H
i IV
• Clopidogrel and aspirin
significant luminal narrowing of LMCA.
LMCA
• Cardiovascular system
y
was collapsed
p
during
g
the angiography.
• IABP was failed
f l d to advance
d
into d
descending
d
tthoracic
o ac c aorta
ao ta
• Intravenous infusion of inotropics
• Endotracheal intubation with artificial
ventilator support.
support
Final CAG
Direct stenting with drug
elutingg stent (4.0
(
x 16mm,,
PROMUS® Element™,
Boston, USA) was deployed
i LMCA att 10 atm
in
t for
f 5 sec.
T
Transthoracic
th
i echocardiography
h
di
h (TTE)
Reduced EF as 35%, severe hypokinesia of anterior wall
TTE (2)
RV
LV
LV
A
Ao
LA
Apical
p ca five
ve cchamber
a be vview
ew aand
d subcosta
subcostal vview
ew sshow
ow tthee intimal
t a flap
ap of
o
ascending aortic dissection.
B
C
Computed
t d tomography
t
h
left
Ascending aorta dissection began just above
aortic
ti valve
l (white
( hit arrow).
) LMCA stent
t t (black
(bl k
arrow) and dissection of aortic arch (B) was
shown.
The patient was
undergone
g
surgical repair
of ascending
aorta and hemiarch
FOLLOW UP TTE
C l i
Conclusion
• We experienced a case of acute anterior myocardial
infarction with collapsed cardiovascular system
related to left main coronary artery involvement of
AAAD.
AAAD
• We successfullyy treated the left main lesion byy direct
stenting and stabilized hemodynamic status for the
following definitive surgical repair.
repair