Left Anterior Descending Coronary Artery Occlusion Resulting from Concussion by a Bullet

The Video can be viewed in the online version of this article [https://doi.org/10.1016/j.athoracsur.2018.07.057] on http://www.annalsthoracicsurgery.org. The Video can be viewed in the online version of this article [https://doi.org/10.1016/j.athoracsur.2018.07.057] on http://www.annalsthoracicsurgery.org. A 26-year-old man presented to the hospital after a gunshot to his left lower chest that resulted in fractured left lower ribs, a retained bullet in the anterior mediastinum, and hemopneumothorax. Cardiac workup for persistent left-sided chest pain was remarkable for elevated troponin (12 ng/mL [normal: <0.05 ng/mL]) and septal Q waves on the electrocardiogram (18 hours after injury). Echocardiography showed anterior, anterolateral, apical, and inferoapical hypokinesis. Computed tomography of the chest showed that the bullet had traversed the anterior mediastinum, and the left anterior descending coronary artery (LAD) flow was not visualized past the midsegment. Coronary angiography showed total occlusion of the mid-LAD (Video). Coronary intravascular ultrasound confirmed the LAD to be 100% occluded; however, the mechanism of occlusion was ambiguous (dissection vs intramural hematoma vs extrinsic compression by localized hematoma). The patient underwent coronary artery bypass graft, including a left internal mammary artery–to-LAD graft after a positive viability study. The pericardium was thickened and had a well-circumscribed defect (Fig 1) with adhesion to the epicardium at the site of LAD occlusion. The mechanism of LAD occlusion was presumed to be an intramural hematoma caused by concussion injury by the bullet. The patient did well postoperatively and was discharged home. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI5YjQwY2Q5YTFlZTYxMmNhNGMwNTZlNjcwZTM5MmYwNCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc3NzkwMzU2fQ.QiNDO3g9h8Y-24vZDWHQPBj3EOz_vUP7pCnhTgwptcYdCpRv3sm_EQ-3DdorBNYpVwcIrKP5h2yoEAnXXngzzBJnRxVE3HoQrmGZDD8ujihNXF2nIXAA7QYjMF9XtrGKHrVGpZu1RuNoZSrTrXShzHakcnlbJycxTWHdQvD0zVue8r7Qfb-HEi-gRdxNopVF0pPJt-Pagi816-JVce1lAmrSa5nX1rDKFiwuTuRyj35DOJeKBK5OZJSKfxmjr4fhkXG_9ht8j4ApdjB3Fg83K1lzw3WxBwu6ja295X4KCGx4ScpdQRJLjz_OV9D4BNQPT2v74-Rrv3YRFBv9AhOfNw Download .mp4 (1.34 MB) Help with .mp4 files Video 1