[Dissection of the ramus interventricularis anterior in blunt chest trauma]

A 57-year-old man suffered a blunt trauma to his chest when the car he was driving collided head-on with a stationary lorry. He had worn his seat belt and the air-bag had inflated on impact. He was admitted to hospital because of severe left chest pain that started 45 min after the accident. Admission physical examination indicated stable cardiopulmonary status in a fully conscious person with no obvious physical signs, in particular no contusion or other injury to the chest or fractures.

ECG, echocardiography, chest radiography and routine laboratory tests on admission failed to reveal any diagnostic abnormality. But subsequent ECG and biochemical tests suggested evolution of an acute anterior wall infarction, leading to the patient's transfer to the author's hospital.

A coronary angiogram revealed traumatic dissection of the anterior interventricular branch (AIVB) around the origin of the first diagonal branch. There was also suspicion of thrombus formation and clearly impaired left ventricular function with hypo- to akinesia of the anterior wall. Myocardial scintigraphy, positron emission tomography and stress echocardiography were performed to assess the possible need for interventional or surgical revascularization. They demonstrated functioning myocardial tissue in most of the anterior wall so that minimally invasive AIVB-bypass operation was planned.

The possibility of severe injury of the heart and other organs even after primarily blunt chest trauma demands careful follow-up monitoring and, if indicated, extensive noninvasive as well as invasive diagnosis and treatment.