Idiopathic Right Coronary Artery Rupture: A Rare Diagnosis in Young Adults

Objectives: Idiopathic coronary artery rupture is a rare cardiac emergency associated with an unfavorable outcome, especially since diagnosis may be difficult and, as a result, surgical treatment may be delayed.

Methods: We report on a 41-year-old policeman who was emergently admitted to the hospital with acute retrosternal pain radiating into his neck and shortness of breath with an otherwise blunt past medical history, except for smoking. During transportation, the patient required CPR due to bradycardia for at least 3 minutes, however, on admission to the emergency department the patient was awake and hemodynamically stable.

Results: Acute cardiac tamponade with cardiac compromise was diagnosed via transthoracic echocardiography. Emergent CT scan not only confirmed the diagnosis of hemopericardium but also showed suspicious changes in the ascending aorta indicating an intramural hematoma, possibly due to acute type A aortic dissection (Fig. 1). Due to progressive hemodynamic instability the patient was immediately transferred to the operating room. Intraoperatively, acute type A dissection with intramural hematoma was excluded after aortotomy. Subsequently, the cause of hemopericardium was identified as an idiopathic perforation of the right posterior descending coronary artery (Fig. 1). Reconstruction of the ruptured vessel with a saphenous vein patch was performed using CPB and cardioplegic cardiac arrest under moderate hypothermia. The postoperative course of the patient was uneventful. Tissue samples of the coronary artery, epicardium and ascending aorta showed signs of fibrinous-/hemorrhagic epicarditis.

Fig. 1

Conclusion: Idiopathic coronary artery rupture may be successfully managed by open surgery. Fibrinous-/hemorrhagic epicarditis, as confirmed by histopathologic examination, may potentially cause this lethal coronary artery pathology. In young patients-unlikely to suffer from cardiovascular pathology-presenting with acute cardiac tamponade idiopathic coronary artery rupture should be considered as a possible differential diagnosis with subsequent immediate interventional or surgical treatment.