A Misleading Diagnosis: Anterolateral STEMI Disguising Type A Aortic Dissection in Postpartum

Balina Hema, Wool Thomas
2020 International Journal of Clinical Cardiology  
In the lab she was found to be increasingly hypoxemic and had an episode of vomiting, requiring intubation. Transthoracic echocardiogram showed mild -moderate left ventricular dysfunction with no pericardial effusion. The right femoral artery and vein were accessed percutaneously. A 6 -French JR4 catheter over a J wire was advanced into the ascending aorta, however due to difficulty encountered in passing the catheter through aortic valve, there was a suspicion for aortic dissection and
more » ... n through Judkins catheter confirmed the presumed diagnosis ( Figure 2 ). Thoracic aortogram with a pig tail catheter outlined the presence of flap ( Figure 3 ). There was also compression and narrowing of left main artery, with 90% occlusion and sluggish flow through the left sided circulation. Due to hypotension, severe left main stenosis and very poor blood flow in the left sided circulation, stenting was performed with the help of a 4 x 12 mm bare metal stent alleviating the high grade stenosis ( Figure 4 ). Her blood pressure stabilized following the procedure, however she was found to be in persistent wide complex tachycardia with a heart rate in 140-150's bpm. Her rate and rhythm remained unchanged despite amiodarone and synchronized cardioversion. Surgical intervention for aortic repair was attempted. She was then immediately moved into a helicopter for transferring her to a higher level facility for aortic repair. Unfortunately, she went into cardiac arrest with pulseless electrical activity and passed away. A 39-year-old Caucasian woman presented to the outside hospital with complaints of one hour of excruciating retrosternal chest pain, dyspnea and diaphoresis. Ten days prior to the presentation, patient underwent an uncomplicated vaginal delivery. Her pregnancy was complicated by moderate gestational hypertension. Electrocardiography (ECG) showed ST segment elevations in leads aVL, aVR, V2 and V6 with reciprocal changes in II, III and aVF ( Figure 1 ). Laboratory data was significant for troponin 0.158 ng/mL, Brain natriuretic peptide (BNP) 70 pg/mL and D-Dimer 2.08 mg/L. She received aspirin, clopidogrel and heparin prior to transfer to our facility for left heart catheterization. When she arrived at our ER, she continued to report chest pain and dyspnea. She was hemodynamically unstable with blood pressure 53/23 mmHg, heart rate 74 beats/minute, respiratory rate 20/minute and an oxygen saturation of 95% on 100% oxygen via non-rebreather mask. She was immediately placed on dopamine drip and moved to the catheterization lab. Abstract Acute Myocardial Infarction (AMI) during the early postpartum period is a rare event and carries a high mortality rate. We report an unusual case of Type A aortic dissection involving the left coronary ostium and presenting as anterolateral ST segment elevation myocardial infarction. Our patient was diagnosed to have aortic dissection at the time of left heart catheterization, and suffered a cardiac arrest prior to undergoing surgical intervention.
doi:10.23937/2378-2951/1410177 fatcat:ia2t2ho4zrcyziw3kmhmzvzcda