Acute myocardial infarction caused by aortic dissection mani
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A 78-year-old woman suffered sudden chest pain at 2 a.m., though she endured the symptoms and was transported to the emergency room 6 h later. The blood pressure on the right and left arm was 108/62 and 100/54?mmHg, respectively. An electrocardiogram demonstrated complete atrioventricular block, abnormal Q wave, and ST elevation in II, III, and aVF leads, suggesting an acute inferior myocardial infarction (MI). Emergency coronary angiography was considered; however, an echocardiography revealed a large mass in the ascending aorta, moving distally in systole and retracting into the coronary cusp in diastole, accompanied by severe hypokinesis of inferior wall and right ventricle.

Since it was assumed that the mass in the ascending aorta was obstructing the coronary blood flow, contrast-enhanced computed tomography (CT) was immediately performed instead of coronary angiography. The CT scan showed a Stanford type A aortic dissection (AD), with a pseudo-lumen opening.

The inferior part of the pseudo-lumen was occluded by a thrombus, consistent with the mass visualized on echocardiography. On laboratory tests, D-dimer levels were markedly elevated (505??g/dL), and CK and CKMB elevated (440?U/L and 69?U/L, respectively).

Emergency surgery was performed, revealing that the thrombus in the false lumen obstructed the right coronary artery (RCA); RCA flow was restored by removing the thrombus. After the operation, the patient underwent rehabilitation and was discharged.

According to the literature, coronary malperfusion occurs in 6–11% of type A AD cases, and the prognosis is worse when AD is complicated with coronary malperfusion. It is important to differentiate between a usual MI and coronary malperfusion due to AD, and echocardiography is a useful modality because it can diagnose AD with high sensitivity and can be performed quickly.

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