Aortic Sinus Dissection Causing STEMI

Figures

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  Figure 1. Emergency Electrocardiogram Indicates Acute Inferior Wall STEMI The first electrocardiogram obtained in the emergency department showed sinus rhythm with ST-segment elevation in leads II, III, and aVF (red boxes) and ST-segment depression in leads V2 to V5. These findings are consistent with a typical acute inferior wall ST-segment elevation myocardial infarction (STEMI).

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  Figure 2. Coronary Angiography Images (A) Anteroposterior cranial view, (B) hepatic view, and (C) spider view angiography images indicate no significant stenosis in the left main coronary artery (green arrows), left anterior descending artery (white arrows), and left circumflex artery (yellow arrows). (D) Complete occlusion is seen from the proximal segment of the right coronary artery (red arrows).

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  Figure 3. Emergency PCI Successfully Opened the Culprit Right Coronary Artery Caused by Sinus of Valsalva Dissection Emergency PCI procedure: (A) A SAL 1.0 catheter was engaged in the RCA ostium (white arrows). A Runthrough guidewire failed to cross the lesion after multiple attempts. (B) Aortography showing the true RCA ostium. The white arrows indicate severe stenosis at the RCA ostium and proximal segment. (C) Successful engagement of the RCA with an Amplatz left 1.0 catheter for angiography. The white arrows show compression of the RCA ostium and proximal segment by a hematoma caused by an aortic sinus dissection. (D) A Runthrough guidewire successfully crossed the proximal RCA lesion and was advanced to the distal RCA. (E) A Sion guidewire (green arrows) was placed at the RCA ostium as a tangent wire to facilitate stent positioning proximally. The white arrows show the positioning of a Medtronic 3.5 × 38 mm stent. (F) Image after stent implantation from the RCA proximal segment to the ostium. The stent sealed the coronary hematoma caused by the dissection, with good stent expansion and apposition. TIMI flow grade 3 was achieved, indicating a successful procedure. PCI = percutaneous…

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  Figure 4. Postoperative Coronary CTA Confirms Right Coronary Sinus Dissection Leading to Myocardial Infarction (A and B) The aortic root is significantly dilated, with a maximum diameter of 63.08 mm (green measurement line in A). (C, D, and E) A localized intimal tear in the wall of the right coronary sinus is displayed from different planes (green arrows), which extends to involve the RCA ostium. The yellow arrows indicate the radiographic visualization of the implanted stent. (F) Three-dimensional reconstruction indicating multiple dissections in the aortic sinus extending to involve the RCA ostium (green arrows); the yellow arrows demonstrate RCA patency after stent implantation. CTA = computed tomography angiography; RCA = right coronary artery.

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  Figure 5. Retrospective Analysis of Preoperative Aortic CTA: Right Coronary Sinus Dissection Causing Myocardial Infarction Preoperative aortic CTA images of the patient before emergency PCI show that the aortic sinus dissection involves the ostium and the proximal segment of the RCA, leading to the acute myocardial infarction. In the (A) axial and (B) sagittal planes, the sinus of Valsalva dissection (green arrows) extended to involve the RCA ostium (red arrows), which caused the myocardial infarction. (C) Three-dimensional reconstruction providing a detailed view of how the sinus of Valsalva dissection (green arrows) involves the RCA ostium (red arrow), resulting in occlusion of the proximal RCA and consequently the myocardial infarction. CTA = computed tomography angiography; PCI = percutaneous coronary intervention; RCA = right coronary artery.

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  Figure 6. Intraoperative Exploration Revealed Neri Type B Dissection Neri classification of Stanford type A aortic dissection involving the coronary arteries: (A) Type A: luminal dissection confined to the coronary artery ostium. (B) Type B: luminal dissection extending into the coronary artery with formation of a coronary false lumen. (C) Type C: sleeve-like dissection and rupture of the coronary intima. In this patient, intraoperative exploration revealed Neri type B dissection.