Change in Heart: Traumatic left anterior descending arterial thrombus and dissection following blunt chest trauma in a patient requiring multiple interventions and ultimately a heart transplant: A case report.
Abstract
Introduction: Blunt chest trauma may provoke various thoracic and cardiac injuries. Rarely, patients may develop life threatening coronary artery injuries. Early detection is critical to reduce morbidity and mortality.
Case Information: A 24-year-old male presented to the emergency department with complaints of chest pain with breathing following blunt chest trauma sustained in a motorcycle accident in which he was thrown from his motorcycle. On exam, the patient was tachycardic with bruising noted to the right anterior lower ribs and tenderness to palpation overlying the anterior middle chest wall. The patient received trauma protocol CT scans of the head, cervical spine, and combined chest, abdomen, and pelvis. He was noted to have a non-displaced sternal fracture in addition to a right lower lung contusion and mild vertebral compression fractures at T4 and T6. Cardiac enzymes were initially mildly elevated with subsequent significant elevation with associated ECG changes. Echocardiogram revealed reduced biventricular function with a decreased ejection fraction. Coronary angiography demonstrated a left anterior descending thrombus with arterial dissection requiring thrombectomy and coronary artery stenting. Patient improved and was soon discharged home. Approximately one week later, the patient developed pericarditis with pericardial effusion and tamponade physiology requiring pericardiocentesis and pericardial window. His admission was further complicated by hemorrhagic shock and intra-abdominal bleeding requiring exploratory laparoscopy for control of the hemorrhage. The patient was eventually discharged with a LifeVest wearable defibrillator. Several months later, the patient presented to the emergency department for ventricular tachycardia arrest after removing his LifeVest to ride his motorcycle. Cardiothoracic surgery was consulted for cardiogenic shock, and the patient underwent Impella support and ultimately a heart transplant. His postoperative course was complicated by bradycardia requiring theophylline. The patient eventually improved and was discharged in stable condition with future consideration of a permanent pacemaker.
Discussion/Clinical Findings: While most patients do not undergo such a significant hospital course, it is imperative to suspect cardiac injury in a patient with blunt chest trauma to reduce morbidity and mortality. Chest trauma protocol with cross-sectional imaging combined with ECG, cardiac enzymes, and patient observation is essential in quickly recognizing cardiac injury.
Conclusion: Coronary artery injury such as thrombus and/or dissection following blunt chest trauma is an uncommon but life-threatening presentation. Appropriate imaging, ECG, and cardiac enzyme monitoring are critical in prompt recognition and diagnosis to prevent significant morbidity and mortality.