STEMI: Wolf in Sheep’s Clothing With Double-Barrel Aorta

Abstract

Acute aortic dissection is a life-threatening condition with high mortality if not treated immediately. We present a case of acute aortic dissection presenting as acute ST elevation myocardial infarction causing Cath Lab misadventure and delay in the definitive management.

Case Summary

A 45-year-old smoker and diabetic patient presented with acute onset chest pain and diaphoresis for two hours. His electrocardiogram showed ST elevation in inferior leads (Figure 1A) and he was taken for primary angioplasty immediately. However, right coronary artery (RCA) selective angiogram via radial route showed proximal RCA dissection followed by total occlusion (Figure 1B) with dissection extending into aortic root and ascending aorta (Figure 1C). Procedure was abandoned and he was referred to our hospital for further management. Echocardiogram revealed dissection flap in ascending aorta and aortic arch (Figure 2A), mild left ventricular systolic dysfunction, and mild aortic regurgitation with regional wall motion abnormality in inferior wall segments. His chest X-ray showed double-barrel shadow (Figure 2B) in descending thoracic aorta. CT aortogram revealed Type 1 DeBakey acute aortic dissection extending from aortic root (Figures 2C and 2D), descending thoracic aorta to abdominal aortic bifurcation. Dissection flap extended into RCA. Patient underwent successful dissection repair with grafting to RCA. This emphasizes a rare presentation of aortic dissection as ST-elevation myocardial infarction and critical evaluation of simple tests as chest X-ray and echocardiography before taking for angiogram can avoid Cath Lab nightmares.^{1, 2}

Figure 1.

(A) 12-Lead electrocardiogram showing ST-elevation in inferior leads. (B,C) Right coronary angiogram showing dissection involving proximal right coronary (arrow) extending into ascending aorta and aortic root (arrows).

Figure 2.

(A) Transthoracic echocardiogram in parasternal long-axis view showing dissection flap in ascending aorta (arrows). (B) Chest X-ray PA view (yellow arrows: dissection flap, red arrows: outer aortic wall creating double barrel shadow). (C,D) CT aortogram coronal section showing aortic dissection involving descending thoracic aorta, aortic root, and ascending aorta.

Author Contributions

SM: Conceptualization: equal; formal analysis: lead; writing—original draft: lead; writing—review & editing: lead; HKS: investigation: equal; supervision: equal; validation: equal.