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Multiple coronary rupture after blunt chest trauma
  1. K Dimopoulos,
  2. A Angelini,
  3. R Mencarelli,
  4. G Thiene
  1. cardpath{at}

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A 78 year old woman with a history of hypertension underwent elective hip arthroprosthesis. Three days later, the patient accidentally fell resulting in luxation of the arthroprosthesis, which was reduced under spinal anaesthesia. Severe hypotension occurred soon after. A chest x ray showed massive left pleural effusion and blood tests documented anaemia that required transfusion. ECG showed new onset atrial fibrillation with a mean ventricular rate of 110 beats/min and chronic left bundle branch block. Transthoracic echocardiography performed at bedside, although suboptimal, showed normal left and right ventricles, near normal left ventricular ejection fraction, and approximately 700 ml of pericardial effusion. The patient died suddenly and a postmortem examination was performed.

Necropsy revealed haemopericardium with no signs of heart rupture. A fistula from the anterolateral surface of the left ventricle to the intermediate coronary artery was present. Histology confirmed the rupture of two branches of the intermediate coronary artery, with sharp edges, fibrin stratification, and infiltration of blood into the subepicardial layers adjacent to the two arteries (panels A–D). Multiorgan stasis, centrolobular hepatic necrosis, and bowel infarction were also present.

Blunt thoracic trauma resulting in coronary artery rupture is uncommon. Cases of dissection or thrombosis of a coronary artery after chest trauma have more often been described. In our case, the damage of two neighbouring arteries and the sharp edges of the rupture seen on histology leave no doubt on its traumatic origin.

This is to our knowledge the first reported case of multiple coronary artery rupture following blunt chest trauma.

Embedded Image

(A) Histological section of one of the two ruptured branches of the intermediate coronary artery. Note the sharp edges of the ruptured artery with formation of a pseudoaneurysm and a myocardial bridge that might have contributed to the atypical clinical presentation. Reactive fibrous pericarditis is also present (elastic van-Gieson stain). (B) A close-up view of (A). (C) Histologic section of the second ruptured intermediate branch with formation of a large pseudoaneurysm. (D) Close-up view of the site of rupture. Note the deposition of fibrin (in red) on the walls of the pseudoaneurysm (arrows) (trichrome stain Haidenhaim).