P343 WHAT IS HIDING BEHIND A ‘STEMI‘?

Abstract

Abstract Introduction Stanford type A aortic dissection associated with ST–segment elevation myocardial infarction (STEMI) is a rare event with a high mortality rate. Emergency coronary angiography and antithrombotic therapy expose to a greater risk of complications and mortality. Case presentation: A 57–year–old heavy smoker gentleman with no previous medical history was admitted to the emergency department due to the sudden onset of severe oppressive chest pain. The ECG was suggestive of inferior STEMI and thus he was brought to the cath lab. During coronary angiography, there was spontaneous regression of the ST–segment alterations with persistence, however, of chest pain. The coronary angiography was unremarkable, but the cannulation of the right coronary artery was unexpectedly difficult. In light of the clinic and the suspicious fluoroscopic images (dilated aorta and severe valvular calcifications), an aortography was performed showing a type A aortic dissection. CT angiography confirmed the presence of dissection confined to the ascending aorta with origin of the right coronary artery from the false lumen. The supra–aortic trunks were not involved by the dissection. A bicuspid aortic valve and a bovine trunk were also found. The patient therefore underwent emergency cardiac surgery: a composite aortic valve conduit (Bentall procedure) was implanted and double aorto–coronary bypass surgery was performed, due to intraoperative evidence of complete detachment of the right coronary ostium and partial detachment of the left. The operation was successful and the following hospitalization was uneventful. Conclusions This case report exemplifies an important alternative diagnosis in patients referred for STEMI, particularly if with an inferior localization (the right coronary artery is the most frequently involved by the dissection). It is necessary to pay attention to the possible clues coming from the clinical findings and from the radioscopic and angiographic images obtained in the cath lab in order not to miss the diagnosis of a pathology on whose recognition and timely treatment the patient‘s life depends.