P304 ACUTE ST–ELEVATION MYOCARDIAL INFARCTION DUE TO AORTIC DISSECTION: HISTORY OF A LATE DIAGNOSIS AFTER PRIMARY ANGIOPLASTY

Abstract

Abstract Introduction We report a case of aortic type A dissection, involving the right coronary ostium, presented as an inferior STEMI. The aortic dissection diagnosis was formulated only after the coronary angioplasty on the right coronary was successfully done, leading to chest pain resolution. Dual antiplatelet therapy was administered. We want to underline how sometimes, mostly in emergencies, can be difficult to do the right diagnosis at the right time, even if some angiographic findings could help us to avoid life–threatening mistakes. Case presentation: 60 years–old man with typical angina chest pain started after an effort. The electrocardiogram showed ST elevation in inferior leads, while the echocardiogram akinesia of the inferior wall, a preserved EF, a normal diameter of the aortic root, no dissection signs, no pericardial effusion. The coronary angiography showed ostial RCA occlusion, critical stenosis in mid–distal LAD. Angioplasty on the RCA ostium with one drug–eluting stent (DES 3.5 x 18 mm) achieving reperfusion with TIMI 3 flow, complete resolution of ECG alteration and symptoms. Then PCI of LAD with DES was performed. During hospitalization in ICU recurrence of mild chest pain without ECG alterations. Routine echocardiogram performed the following day showed signs of aortic root dissection and moderate aortic valve regurgitation; an angio–CT scan was immediately performed confirming the aortic dissection, and cardiac surgery was immediately performed with good result. Reanalysis of the angiographic images showed some signs that should have made us think right away of an aortic dissection: abnormal convexity of the right coronary sinus, extravascular stagnation of contrast medium, and ostial RCA stent create a communication between the real and the false lumen, visible at the final injection. Conclusion Aortic root dissection, involving coronary ostium, could be a sneaky diagnosis since signs and symptoms could be very similar to myocardial infarction ones. A correct diagnosis is very important, leading to the right surgery treatment, the PCI and the dual antiplatelet therapy could lead to worsening outcomes. It is mandatory to pay attention to the signs that could help us doing the right diagnosis when we are performing coronary angiography. Always check the patient accurately during the ICU stay in order not to lose signs that can let us change the wrong to the correct diagnosis.