Case Report: Cardiac arrest due to traumatic coronary artery dissection treated by extracorporeal membrane resuscitation

Introduction

Traumatic coronary artery dissection is rare but delayed diagnosis of this condition can lead to life-threatening¹. We report a case of cardiac arrest in emergency department (ED) due to traumatic coronary artery dissection, which is treated with extracorporeal membrane oxygenation (ECMO) and extracorporeal cardiopulmonary resuscitation (ECPR).

Case presentation

A 44-year-old man with no previous history of heart disease had a traffic accident, his vehicle ramming into a wall. There were no witness and no information about the speed and mechanism of accident. On arrival of emergency medical service personnel at the scene, he had an open airway, a respiratory rate of 24 breaths/min, a blood pressure of 68/32 mmHg, a pulse rate of 120 beats/min and a Glasgow coma scale of E4V2M4. After 30 minutes, he was transferred to the ED of our hospital. Just before his arrival to the ED, he had a sudden ventricular fibrillation (VF). The VF was refractory to defibrillations, 5 mg epinephrine and 150 mg amiodaron; no abnormal findings was detected in focused assessment with sonography for trauma. After 11 minutes, we initiated to switch conventional CPR to ECPR. Two minutes after introducing ECPR, his electrocardiogram recovered from VF to sinus rhythm with ST-elevation at V4–6. Echocardiography revealed hypokinesis of the basal and anterior septal segment with an ejection fraction of 20% without pericardial effusion. He also had right scapula fracture, left chest wall hematoma, spleen laceration and open left femoral shaft fracture, which needs external fixation (Injury Severity Score38, probability of survival by Trauma Injury Severity Score=3.9%). We prioritized coronary angiography due to a suspicion of acute coronary syndrome. The coronary angiography and intravascular ultrasound (IVUS) supported with ECMO revealed complete occlusions of left anterior descending (LAD) and left circumflex (LCX) artery due to dissections of distal left main coronary artery (LMA) without atheroma; normal right coronary artery was normal (Figure 1, Figure 2). Drug-eluting stents were placed 3 hours after admission: 1 in #6–7 and #11–13 with restorations of TIMI 2 flows of LAD and LCX. Subsequently, he was treated for the open femoral fracture with external fixation and then admitted to the intensive care unit (ICU). After ICU admission, his left ventricular function gradually recovered; he was successfully weaned from VA-ECMO on day 9. Despite recovery from traumatic injuries, he had acquired cytomegalovirus and candida infections (diagnosed on day 23 of his hospital stay by bronchoalveolar lavage) in hospital due to his compromised status, he had no infections on admission. Medical therapy with 1.25 mg/kg/day ganciclovir for 19 days and 150 mg/day micafangin for 13 days had been introduced, but he died on day 51 because of advanced multiple organ failure due to resistant virus infection.

Figure 1. Angiography of left main trunk before (left) and after (right) percutaneous coronary intervention.

Figure 2. Maximum intensity projection image of coronary artery made from computed tomography.

Arrows indicates the site of coronary artery dissection.

Discussion

Acceleration and deceleration forces of blunt trauma potentially causes vascular spasm, intimal tears, dissection or a rupture of an existing plaque within the thrombus formation in coronary arteries, which can result in acute coronary syndrome after trauma^2,3. In the present case, intimal tears caused non-atherosclerotic myocardial infarction. In a previous report including 76 cases of traumatic acute myocardial infarction⁴, which included 12 cases with coronary artery dissection, LAD was most frequently affected (LMA, 6.4%; LAD, 71.4%; RCA, 19%; LCX 3.2%); in the present case, the distal LMA were dissected. Spontaneous coronary artery dissection is an increasingly recognized cause of non-atherosclerotic myocardial infarction⁵. However, the right scapula fracture, left chest wall hematoma and spleen laceration, which was located on the same coronary plane may be evidence of traumatic dissection. Since reported incidence of cardiac injury in blunt thoracic trauma was 0.3% in the U.S. National Trauma Data Bank, cardiac injury is relatively rare⁶.

Bleeding is the most common complication during ECMO; the use of ECMO in patients with trauma of bleeding shock is uncommon⁷. The literature search of ECPR in trauma during 1974–2018 identified 67 trauma patients who had cardiac arrest treated with ECPR (bleeding shock=14, severe pulmonary contusion=6, hypothermia=3, hypoxia=1, unknown=24)^8–17, but not refractory VF due to AMI or coronary dissection. Recent guidelines from the American Heart Association concerning cardiac arrest described the following: “ECPR may be considered for select patients for whom the suspected etiology of the cardiac arrest is potentially reversible during a limited period of mechanical cardiorespiratory support”¹⁸. In the present case, percutaneous intervention to the coronary dissection was successfully performed in the hemodynamically stable condition by ECMO.

To conclude, traumatic coronary artery dissection potentially leads to development of refractory VF on ED. ECPR may be a valuable option to allow time and a stable hemodynamic condition to treat the cause of cardiac arrest.

Data availability

All data underlying the results are available as part of the article and no additional source data are required.

Consent

Written informed consent for publication of clinical details and images was obtained from the patient and his parent.