胸部钝性外伤性急性心肌梗塞2例报告及文献复习

本文报告2例青年于胸部钝性外伤后出现心肌异常Q波和损伤性ST段抬高，其心电图和心肌酶学的演变与典型的急性心肌梗塞（AMI）相同。胸部钝性外伤致AMI的主要机理为冠状动脉内膜扯裂、内膜下出血、血栓形成以及粥样斑块扯裂而导致冠状动脉阻塞，受累最多的是左前降支。由于常伴体表、心脏或其它脏器的挫伤或损伤，全身抗凝或静脉溶栓治疗通常为禁忌。如病人条件允许，可施行冠脉搭桥、PTCA或冠状动脉内溶栓等治疗。     

Acute myocardial infarction caused by coronary artery dissection after a blunt chest trauma

Acute myocardial infarction is a life-threatening condition. Coronary dissection after blunt chest trauma is a rare event. Chest pain is a common symptom after chest trauma, which may relate to chest contusion without cardiac injury or myocardial infarction. Differentiation between minor cardiac contusion and significant cardiac injury is difficult and it is a challenge for physicians to diagnose traumatic cardiac injury early. We report a case of a 40-year-old man suffering from coronary artery dissection after a blunt chest trauma and intracranial hemorrhage after percutaneous coronary intervention.     

A case of blunt chest trauma induced acute myocardial infarction involving two vessels

Blunt chest trauma rarely induces acute myocardial infarction. We report a 36-year-old man who suffered from blunt trauma to the anterior chest wall while operating a punching machine. This case is the first report of simultaneous blunt chest trauma to the left anterior descending artery and left circumflex artery. The patient was treated surgically and discharged without any serious sequela. Early detection of the lesion site is important with regard to selecting the appropriate treatment strategy in patients with coronary injury caused by blunt chest trauma. Routine 12-lead electrocardiography and serial cardiac enzyme evaluation are necessary in every patient with chest trauma because they supply crucial information about the extent of cardiac damage. Treatment with primary angioplasty or bypass surgery should be based on the characteristics of the lesion and the associated problem.     

Results of Stent Supported Percutaneous Transluminal Coronary Angioplasty in Octogenarians With Coronary Artery Disease

Between January 1995 and July 1998, percutaneous transluminal coronary angioplasty was performed on 27 lesions in 24 octogenarians. Half of the patients were African American. Women comprised 67% of the study group. Patients with unstable angina and myocardial infarction constituted 54% of the cohort. Two-thirds of the patients (83%) had single vessel disease with predominant class A and B lesion complexity of the angioplasty site. Acute success rate was 92%. Stents were successfully placed in 11 subjects (46%). None had acute myocardial infarction, emergency coronary artery bypass surgery, or stroke as a complication of the procedure. One patient presenting with acute myocardial infarction complicated by cardiogenic shock, died. Significant bleeding complications requiring blood transfusions occurred in 17% of patients. Of the patients, 23 (96%) were discharged in a clinically stable condition. Follow up during a two year period was completed in 21 patients (88%). One patient died of cancer. Four subjects (19%) underwent repeat percutaneous transluminal coronary angioplasty. One other patient had recurrent chest pain requiring multiple hospitalizations. The remaining 16 patients (76%) remained free of recurrence of angina. We concluded that percutaneous transluminal coronary angioplasty with stent placement can be performed in octogenarians with a high rate of clinical and angiographic success with an acceptable range of morbidity and mortality, and favorable long term (two year) outcome.     

硫氮酮治疗经皮腔内冠状动脉成形术中冠状动脉痉挛的效果

目的探讨急性心肌梗死患者经皮腔内冠状动脉成形术中冠脉内注射硫氮艹卓酮治疗冠脉痉挛的效果。方法39例术中发生冠脉痉挛病例,分别注射硫氮艹卓酮和硝酸甘油并进行比较。结果硫氮艹卓酮组20 s、40 s痉挛缓解率分别为85%、15%,总缓解率100%;硝酸甘油组20 s、40 s缓解率79%、11%,总缓解率89%,两组比较无显著差异。冠状动脉内应用硫氮艹卓酮1、3、5和10 m in心率、动脉血压无显著变化。结论冠脉内注射硫氮艹卓酮和硝酸甘油能同样有效地缓解AM I患者行PTCA中发生的冠脉痉挛,并且无严重的负性变时和降压作用。     

Transient silent ischemia after percutaneous transluminal coronary angioplasty manifested with a bizarre electrocardiogram

Silent myocardial ischemia is recognized as a common manifestation after percutaneous coronary interventions possibly due to induction of coronary artery spasm. A 54-year-old man was performed primary percutaneous transluminal coronary angioplasty with the diagnosis of acute myocardial infarction. His 18-hour control electrocardiogram showed big-notched inverted T waves in precordial, III, and aVF leads without any chest pain. These bizarre electrocardiographic findings were restored after a brief period indicating silent ischemia that is caused by coronary artery spasm.     

Obstruction of the proximal right coronary artery with acute inferior infarction due to blunt chest trauma.

Two patients developed an acute transmural myocardial infarction due to severe obstruction of the proximal right coronary artery after blunt chest trauma. Neither had a history of ischemic heart disease, and both had an arteriographically normal left coronary artery. In one patient significant resolution of the subtotal obstruction occurred within 3 months. An intimal tear or subintimal hemorrhage with luminal thrombosis, or both, are the suggested mechanism of coronary arterial occlusion. Spasm and platelet aggregates may contribute. Despite a large number of automobile accidents, obstruction of the right coronary artery due to blunt chest trauma has not been previously described. This suggests it has been overlooked and should be especially suspected in persons with injury to the sternum and an acute inferior myocardial infarction.     

Primary antiphospholipid syndrome with acute myocardial infarction recanalised by PTCA

A 20 year old man with severe chest pain was hospitalised for acute myocardial infarction. Coronary angiography revealed total obstruction of his right coronary artery, which was successfully recanalised by direct percutaneous transluminal coronary angioplasty (PTCA). There was also diffuse thrombi in the left coronary artery that was not recanalised by perfusion with 3000 U pro-urokinase. Anticoagulant therapy was performed after PTCA. Creatine kinase peaked one day after hospitalisation (4805 U/l). The activated partial thromboplastin time was 62.6 seconds (45%). Plasma anticardiolipin IgG antibodies were high (3.8 and 2.7) in repeated examinations. The PTCA site was patent after three months. Primary antiphospholipid syndrome should be considered as a cause of acute myocardial infarction in young adults, and PTCA with anticoagulant treatment is effective for initial treatment of the syndrome.

Keywords: primary antiphospholipid syndrome;  acute myocardial infarction;  percutaneous transluminal coronary angioplasty     

Acute anterior wall myocardial infarction secondary to blunt chest trauma

We report here a young patient who developed an acute transmural anterior wall myocardial infarction secondary to blunt chest trauma in an automobile accident. At angiography we demonstrated that this patient had sustained a left anterior descending branch intimal tear (Figure 1). Closed chest wall injury with myocardial contusion is a common occurrence in automobile accidents. However, the occlusion of the coronary artery from blunt chest trauma is rare in itself.     

Cardiac tamponade complicating myocardial infarction in the era of thrombolytics and platelet IIb/IIIa: case report and literature review

Pericardial tamponade is a rare complication of acute myocardial infarction. The authors present the case of a patient with a large anterior myocardial infarction administered thrombolytics who developed postinfarction pericarditis. Because of a stuttering course with concomitant postinfarction angina, urgent angiography, leading to percutaneous transluminal coronary angioplasty and stent implantation, was performed. Administration of abciximab prior to percutaneous transluminal coronary angioplasty appears to have precipitated pericardial tamponade. The authors review the literature concerning numerous commonly utilized therapeutic options that could have contributed to the development of pericardial tamponade.     

Hypertrophic cardiomyopathy in a patient with Crohn's disease: a case report

Coronary artery dissection after blunt chest trauma has rarely been reported in traumatic cardiac injuries, but it may cause fatal or nonfatal myocardial infarction. We report a case of dissection of the left main coronary artery, which resulted in acute myocardial infarction 5 weeks after blunt chest trauma. Multidetector-row computed tomography performed prior to the onset of infarction depicted intimal flap and dissected cavities.     

Circumflex coronary artery occlusion after blunt chest trauma

A 32-year-old white male police officer suffered blunt trauma to the anterior chest wall during a routine training session. This was accompanied by the precipitous onset of chest discomfort. There was no previous history of any cardiac risk factors. The diagnosis of an inferior wall myocardial infarction was made based on the electrocardiogram findings, at his local community hospital. The total creatine kinase, creatine kinase-MB, and troponin I were normal. The transesophageal echocardiogram performed at that time demonstrated no aortic or coronary dissection. He was transferred to our tertiary care center. Emergency cardiac catheterization demonstrated lateral wall hypokinesis with a left ventricular ejection fraction of 45% and a total occlusion of the left circumflex coronary artery in its proximal portion. This was successfully recannulized with angioplasty and stenting techniques. We believe this to be only the second reported case of circumflex coronary artery obstruction after blunt chest trauma.     

A complication of prolonged urokinase infusion into a chronically occluded aortocoronary saphenous vein graft

Recanalization of a chronically occluded aortocoronary saphenous vein graft was performed, using a prolonged intracoronary infusion of urokinase followed by percutaneous transluminal coronary angioplasty (PTCA). Despite an angiographically successful result, the patient developed acute myocardial infarction, presumably secondary to distal migration of partially lysed thrombus. One week after successful angioplasty, the graft was once again proximally occluded.     

The spectrum of pathology associated with percutaneous transluminal coronary angioplasty during acute myocardial infarction

The purpose of this study was to determine at necropsy the morphologic consequences of percutaneous transluminal coronary angioplasty performed during acute myocardial infarction. The heart was examined in four patients who died between 6 hours and 4 days after coronary angioplasty. The patients had angioplasty of the left main coronary artery (one patient), left anterior descending coronary artery (two patients) and left circumflex coronary artery (one patient). Necropsy revealed residual stenosis, intimal hemorrhage and plaque disruption in all four patients. Also noted were distal embolization of plaque elements (two patients) and thrombotic occlusion of the coronary artery (one patient). In conclusion, the morphologic changes after angioplasty are varied. These changes illustrate the mechanisms of angioplasty and some of the complications that can be expected in a small number of cases. The morphologic changes associated with coronary angioplasty are similar in patients undergoing elective or emergency angioplasty although medial dissection was not observed in these patients with an evolving myocardial infarction.     

Combined thrombolytic therapy and coronary angioplasty for acute myocardial infarction

From September, 1983, to August, 1984, combined thrombolytic therapy and percutaneous transluminal coronary angioplasty was used to treat 22 cases of acute myocardial infarction. Initial coronary angiograms showed total obstruction in 13 and severe stenosis in 9. Intracoronary infusion of urokinase reopened 7 of 13 totally occluded lesions but left a residual severe stenosis. Coronary angioplasty opened all of the remaining totally obstructed lesions and decreased the stenosis in 14 of 16 stenosed lesions. These procedures were performed 0.5 to 24 hours after the onset of chest pain. Lesions were not successfully dilated in two patients, because of arterial dissection in one and rethrombus formation in the other. One patient died from progressive hypotension beginning during the procedure, despite technically successful coronary angioplasty. Eighteen of the 20 successfully dilated lesions were patent at repeat angiography performed 1 to 3 weeks later. One successfully dilated lesion occluded 8 days after the procedure and was redilated by a larger sized balloon.     

Left main dissection complicating blunt chest trauma: Case report and review of literature

Coronary artery injury after blunt chest trauma is rare, but can be life-threatening, resulting in severe myocardial ischaemia and acute myocardial infarction. We report a case of a 56-year-old male who presented a few days after a blunt chest trauma with crescendo unstable angina. Coronary angiography demonstrated left main coronary artery dissection that was fixed with stent implantation. After a blunt chest trauma symptoms and electrocardiographic findings of a coronary dissection can be nonspecific and confounded by the chest tenderness. In such cases careful evaluation to rule out traumatic coronary injuries is warranted and early intervention should not be delayed in the presence of clear evidence of myocardial ischemia.     

Recurrent obstruction and thrombolysis of the right coronary artery

A patient presented twice with the hyperacute phase of inferior wall myocardial infarction. Emergency coronary angiography was undertaken on each occasion and the occluded right coronary artery reopened by intracoronary thrombolysis using urokinase. The patient subsequently underwent successful percutaneous transluminal coronary angioplasty to dilate the underlying subtotal obstructive lesion in the proximal right coronary artery. The sequence of events in this patient demonstrates that (1) acute coronary thrombolysis can preserve ventricular myocardium, (2) recurrent thrombolysis can be performed successfully in the same artery in the same patient, and (3) coronary angioplasty may be an effective method of dilating the underlying coronary narrowing after coronary thrombolysis.     

Traumatic total occlusion of left main coronary artery caused by blunt chest trauma

Myocardial infarction is a rare complication that can occur immediately after a blunt chest trauma. We report a 36-year-old male who experienced a fatal anterolateral myocardial infarction after a nonpenetrating chest injury sustained in a car accident. Injuries of the coronary arteries associated with blunt chest trauma predominantly affect the left anterior descending artery. This is the first case of traumatic complete occlusion of the left main coronary artery (LMCA) demonstrated by coronary angiography.     

Effect of percutaneous transluminal coronary angioplasty on arrhythmias complicating angina.

Four patients who had stenosis of a single major coronary artery which was treated by percutaneous transluminal coronary angioplasty are described. Three had exercise induced myocardial ischaemia complicated by ventricular tachycardia, fibrillation, and sinus bradycardia, respectively. Asystole developed in a fourth patient who had spontaneous chest pain. After successful percutaneous transluminal coronary angioplasty these arrhythmias did not recur spontaneously or on treadmill exercise testing. Percutaneous coronary angioplasty can be effective in preventing arrhythmias complicating acute myocardial ischaemia secondary to stenosis of a single major coronary artery.     

Unprotected left main stenting in acute myocardial infarction

Left main stenosis is a rare cause of acute myocardial infarction. Emergent percutaneous transluminal coronary angioplasty (PTCA) of the left main coronary artery has been shown to have greatly increased procedural and short-term mortality. Stenting decreases the incidence of abrupt closure and has a lower restenosis rate after PTCA. We present a case of a patient presenting in cardiogenic shock due to an acute anterior myocardial infarction who underwent emergent left main coronary artery stenting.