Case 4 Discussion

This case calls attention for a fairly uncommom, highly unrecognized cause of valvular heart disease and subsequent heart failure. Closed chest trauma is well known for its ability to produce myocardial contusions, pericardial tamponade and aortic artery dissection. Only rare cases are described of non atherosclerotic coronary arteries damaged by non penetrating chest injury. This patient is young and, as judged by the normal appearance of his left coronary system, had no apparent reason to have previous coronary artery disease.

It is very important to follow this patients in the subsequent months following recovery from trauma complications, as they can develop congestive heart failure with completely reversible anatomic defects, conferring a better prognosis if diagnosed at a time that left ventricular dysfunction is not so severe as to be irreversible, even after correction of anatomic abnormalities, by means of ventricular remodeling. This process is a consequence of the excessive activation of the sympathetic and renin-angiotensin systems in an attempt to compensate for pump failure, leading to a suicidal process of increased contractile failure and further activation of the compensatory mechanisms ( for a complete discussion of this issue, go to Cardiology's section, article on pathophysiology of heart failure )

In conclusion, this case ia an example of coronary artery dissection caused by blunt chest trauma, which was severe enough to restrict blood supply to the postero-inferior papilary muscle and the inferior and lateral ventricular walls, causing myocardial infarction, mitral regurgitation and severe congestive heart failure in a matter of months. It highlights the importance of carefful clinical evaluation shortly after the traumatic event, as well as close follow up of this patients after hospital discharge to prevent irreversible complications.