Letter to the Editor Primary stenting in acute myocardial infarction secondary to right coronary artery dissection following blunt chest trauma. Usefulness of intracoronary ultrasound Rau ´ l Moreno T , Jesu ´s Pe ´rez del Todo, Mercedes Nieto, Francisco Alba, Fernando Alfonso, Juan-Carlos Garcia-Rubira, Antonio Ferna ´ndez-Ortiz, Rosana Herna ´ndez, Carlos Macaya Division of Interventional Cardiology, Cardiovascular Institute, Hospital Clı ´nico San Carlos, Martı ´n Lagos, s/n, 28040 Madrid, Spain Received 14 April 2004; accepted 19 June 2004 Available online 9 March 2005 To the editor: Heart injury after blunt thoracic trauma include myocar- dial contusion or haemorrhage, arrhythmia, cardiac rupture, valvular injury, and acute myocardial infarction [1,2]. Myocardial infarction secondary to chest trauma is usually due to coronary thrombosis, coronary dissection or, even more rarely, external compression of the lumen by haemorrhage [3]. Coronary artery dissection secondary to chest trauma is very uncommon, and it is even more rare when it affects the right coronary artery [3–7]. We report a patient with a proximal right coronary artery dissection secondary to chest trauma that was successfully treated with coronary stenting. A 17 year-old patient suffered a car collision by his right side while he was cycling on his bicycle. He was hospitalised and diagnosed of right femur fracture and lung contusion. Afterwards, he presented chest pain associated to ST-elevation at inferior leads. Transthoracic echocardiog- raphy showed akinesia of the inferior and posterior wall of the left ventricle, and absence of pericardial effusion. Blood pressure was 130/85 mm Hg. Coronariography was performed 9 h after the accident, and showed an angio- graphically normal left coronary artery. Right coronary artery had an upper origin and a dissection was located at its proximal segment. Just a moderate lumen narrowing and a TIMI (Thrombolysis In Myocardial Infarction) flow grade 3 was present in this artery (Fig. 1). An intravascular ultrasound study was performed, showing a relatively echogenic, crescent-shaped image at the proximal segment of the artery, consistent with an intimal dissection and confined and subtle subintimal hematoma. The ostium was preserved, ruling out the combination with a dissection of the aortic root (Fig. 2), and the adventicia was undamaged. A 4.0Â23 mm Express stent was directly implanted at the proximal right coronary artery with excellent angio- graphic result (Fig. 3). The subsequent clinical course was uneventful, and creatine-phosphokinase peak value was 3900 IU. Transthoracic and transoesophageal echocardiog- raphy ruled out aortic dissection. Coronary dissection after chest trauma most often affects the left coronary artery [4], but right coronary artery dissection has also been described [5–7]. Coronary dis- section in this setting could be due to the impact and deceleration in horizontal and cranial directions, as it occurs in the case of aortic dissection secondary to chest trauma [8]. In our patient, the upper origin of the right coronary artery could have favoured its proximal dissection. Primary angioplasty is the best reperfusion strategy in patients with ST-segment elevation acute myocardial infarc- tion, since it allows an early identification of the culprit vessel, as well as a successful coronary recanalization in most cases [9]. Therapeutic approach in patients with coronary dissection secondary to blunt chest trauma is controversial. Some cases have been treated with surgical repair [7]. Other authors advocate conservative management in absence of ongoing ischaemia, due to the possibility of spontaneous healing of coronary tear [10]. However, 0167-5273/$ - see front matter D 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2004.06.021 T Corresponding author. E-mail address: raulmorenog@terra.es (R. Moreno). International Journal of Cardiology 103 (2005) 209 – 211 www.elsevier.com/locate/ijcard