Camaro Cyril, Wouters Noëmi T A E, Gin Melvyn Tjon Joe, Bosker Hans A
Department of Cardiology, Rijnstate Hospital, PO Box 9555, 6800 TA Arnhem, The Netherlands.
Am J Emerg Med. 2009 Sep;27(7):899.e3-6. doi: 10.1016/j.ajem.2008.11.007.
Diagnosing acute Stanford type A aortic dissection with the uncommon involvement of the left main coronary artery(LMCA) remains challenging for the emergency physician because it can resemble acute myocardial infarction with cardiogenic shock. The following case report illustrate this infrequent but critical situation. A 52-year-old woman with a history of hypertension awakened with acute retrosternal chest pain accompanied by nausea and vomiting. She was referred to our hospital for primary coronary intervention because of acute myocardial infarction with cardiogenic shock. Coronary angiography indeed revealed LMCA occlusion. Subsequently successful percutaneous coronary intervention with stent implantation was performed, followed by immediate clinical improvement of the patient. Soon after admission at the coronary care unit, severe chest pain, hypotension, and electrocardiographic signs of diffuse myocardial ischemia relapsed. Control coronary angiography,however, showed no in-stent thrombosis. Review of clinical examination revealed an aortic regurgitation murmur. Because of this dynamic pattern of (1) signs of acute myocardial ischemia, (2) relapse of hemodynamic collapse, and (3) unaltered control coronary angiography together with the confirmed aortic regurgitation at transthoracic echocardiography, the patient was suspected of having aortic dissection. Transesophageal echocardiography revealed Stanford type A aortic dissection with severe eccentric aortic regurgitation and no pericardial effusion. Emergent valve-sparing aortic replacement was performed. The patient recovered completely. In this case, the lifesaving element was primary coronary intervention with stenting of the LMCA preventing extensive myocardial damage followed by a surgical correction of the aorta.
诊断左主干冠状动脉（LMCA）罕见受累的急性斯坦福A型主动脉夹层对急诊医生来说仍然具有挑战性，因为它可能类似于伴有心源性休克的急性心肌梗死。以下病例报告说明了这种罕见但危急的情况。一名有高血压病史的52岁女性因急性胸骨后胸痛伴恶心呕吐而醒来。由于急性心肌梗死伴心源性休克，她被转诊至我院进行冠状动脉介入治疗。冠状动脉造影确实显示LMCA闭塞。随后成功进行了经皮冠状动脉介入治疗并植入支架，患者随后立即临床症状改善。在冠心病监护病房入院后不久，严重胸痛、低血压和弥漫性心肌缺血的心电图体征再次出现。然而，冠状动脉造影复查显示支架内无血栓形成。临床检查回顾发现有主动脉瓣反流杂音。由于存在（1）急性心肌缺血体征、（2）血流动力学崩溃复发、（3）冠状动脉造影复查无变化以及经胸超声心动图证实的主动脉瓣反流这种动态模式，怀疑该患者患有主动脉夹层。经食管超声心动图显示为斯坦福A型主动脉夹层，伴有严重偏心性主动脉瓣反流且无心包积液。紧急进行了保留瓣膜的主动脉置换术。患者完全康复。在本病例中，挽救生命的关键是对LMCA进行支架置入的冠状动脉介入治疗，防止广泛心肌损伤，随后对主动脉进行手术矫正。
