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SHORT COMMUNICATION

Cardiogenic shock due to coronary artery disease associated with interrupted aortic arch

Luís Alberto Oliveira DallanI; Adriano MilanezII; Luiz Augusto F. LISBOAIII; Fabio B. JateneIV

DOI: 10.5935/1678-9741.20130040

INTRODUCTION

Acute pulmonary edema is a severe condition caused by several mechanisms. Its occurrence in association with interrupted aortic arch and coronary heart disease is rare. Recently, we faced a similar serious situation, and the purpose of this brief communication is to discuss the best treatment option for patients in the same condition.

A 61-year-old male patient presented sudden illness on his way to work. As there was an outbreak of H1N1 flu, the test was requested and it was negative. He had a previous stent in the left carotid artery due to an ischemic vascular accident four years ago. He developed acute pulmonary edema a few minutes after being admitted to the emergency room, requiring mechanical ventilation. The chest X-ray revealed pulmonary congestion, presence of Q wave in inferior leads and alteration of ventricular repolarization in the anterior wall. The echocardiogram showed inferior ventricular wall akinesia and marked hypokinesia in the other walls. The cineangiocoronariography showed occlusion of the right coronary artery and a 95% obstruction in the left main coronary artery in addition to an interruption at the descending aorta, just after the left subclavian artery origin (Figure 1). Besides developing unstable hemodynamics, requiring inotropic agents, the patient suffered two more pulmonary edema episodes. for Intra-aortic balloon pump was not an option, because of the aortic disease. Percutaneous coronary intervention with stent in the left main coronary artery was suggested, however two interventional cardiology teams did not accept the case.

 

 

After 10 days in the intensive care unit, we performed an off-pump left anterior descending artery bypass, with a saphenous graft. Mechanical ventilation was discontinued in the first postoperative day, followed by a good recovery. Just before the patient's discharge, a chest angiotomography was carried out to confirm the aortic arch interruption and to evaluate saphenous graft patency (Figure 2).

 

 

DISCUSSION

Interrupted aortic arch is an extremely rare congenital malformation, and only a few cases in adults have been reported [1-4]. In this particular patient, the association of such a severe coronary disease with the interrupted aortic arch might have worsened the pulmonary edema. We chose the simplest surgical approach (saphenous graft to left anterior descending) because we believed that such a critical patient's condition would not let allow a simultaneous correction (tube between ascending and descending aorta as well as myocardial revascularization) [5]. After more than one year of follow-up, patient remains asymptomatic, despite no intervention being done on the interrupted aortic arch.

REFERENCES

1. Alam M, Simpson L, Virani SS, Cheong B, Loyalka P, Civitello AB. Incidental diagnosis of interrupted aortic arch in a 72-year-old man. Tex Heart Inst J. 2009;36(5):494-5. [MedLine]

2. Wong CK, Cheng CH, Lau CP, Leung WH, Chan FL. Interrupted aortic arch in an asymptomatic adult. Chest. 1989;96(3):678-9. [MedLine]

3. Kosucu P, Kosucu M, Dinc H, Korkmaz L. Interrupted aortic arch in a adult: diagnosis with MSCT. Int J Cardiovasc Imaging. 2006;22(5):735-9. [MedLine]

4. Sari I, Davutoglu V, Soydinc S, Ozer O. A case of misdiagnosed interrupted aortic arch as primary hypertension for almost two decades. N Z Med J. 2007;120(1258):U2635. [MedLine]

5. Lisboa LAF, Abreu Filho CAC, Dallan LAO, Rochitte CE, Souza JM, Oliveira SA. Tratamento cirúrgico da coarctação do arco aórtico em adulto: avaliação clínica e angiográfica tardia da técnica extra-anatômica. Rev Bras Cir Cardiovasc 2001;16(3):187-94. View article

Article receive on Wednesday, December 19, 2012

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