AORTIC DISSECTION WITH OCCLUSION OF THE L EFT CORONARY-ARTERY

Aortic dissection is the most common fatal condition that involves the aorta. Occasionally, symptoms mimick acute myocardial infarction lead ing to thrombolytic treatment. Accurate diagnosis in patients with che st pain is therefore essential. We describe a case of acute aortic dis section which resulted in myocardial infarction due to obstruction of the left coronary ostium. A 65-year-old female patient with no previou s cardiac history was admitted to a local hospital because of severe c hest pain of acute onset. Physical examination was normal except for a low blood pressure (90/50 mm Hg), heart rate 45 beats/min and parasth esia in both hands. The ECG showed sinus bradycardia with negative T-w ave in V1 and with 1 mm ST-segment elevation in V3. A chest X-ray was normal. Five hours later, the patient experienced once more severe che st pain followed by nonsustained polymorphic ventricular tachycardia ( Figure 1). Another ECG showed bifascicular bundle branch block (right bundle branch block and left anterior fascicular block). The ECG was i nterpreted as showing acute myocardial infarction and treatment with i ntravenous streptokinase started. Since the patient remained severely hypotensive despite infusion of dobutamine, she was intubated, ventila ted and transferred to our hospital. Cardiac catheterization showed ac ute dissection of the ascending aorta with an aortic intimal flap and an occlusion of the left coronary artery (Figures 2a and b). During ca theterization, she suffered a cardiac arrest from which she could not be resuscitated. A postmortem examination confirmed the acute aortic d issection which reached to the ostium of the left coronary artery (Fig ures 3a and b, 4a and b) and an anterior myocardial infarction probabl y due to intermitted diastolic obstruction of the ostium of the left c oronary artery by an aortic intimal flap.