Acute Myocardial Infarction and Cardiac Arrest in Atypical Takayasu Aortitis in a Young Girl

Abstract

A 16-year-old girl collapsed suddenly while on her way to school. When the rescue team arrived, they found her to be in asystole. Spontaneous circulation was restored after 14 minutes of cardiopulmonary resuscitation. A 12-lead electrocardiogram showed sinus tachycardia and diffuse repolarization abnormalities (Figure 1). An echocardiogram showed moderate aortic regurgitation with severely impaired left and right systolic function. Computed tomography showed increased thickness of the aortic wall extending from the sinotubular junction to the abdominal aorta ( Figure 2). The arch branches, celiac trunk, and renal arteries were normal. The patient was transferred to the cardiac surgery department of our hospital. The chest radiograph showed a normal-size cardiac silhouette but with evidence of interstitial edema (Figure 3). Transesophageal echocardiography showed increased thickness of the ascending and descending aortic wall, with mild aortic regurgitation and severe depression of left and right systolic function. No intimal flap of aortic wall was evident. Six hours after the onset of symptoms, cardiac magnetic resonance imaging showed (1) severe impairment of left systolic function with left ventricular ejection fraction of 15% and akinesis of the anterolateral and apical segments (Movie I of the online-only Data Supplement) (2) moderate aortic regurgitation, (3) increased thickness of the ascending and descending aortic wall in gradient-echo steady-state free precession cine (Movie II of the online-only Data Supplement) in T2-weighted images and in delayed-enhancement images after gadolinium-diethylenetriaminepentaacetic acid contrast medium (Figure 4), (4) dilatation of the ascending aorta with extensive irregularities of the descending aortic wall in angiography ( Figure 5 and Movie III of the onlineonly Data Supplement), (5) subendocardial delayed enhancement of the left ventricular anterolateral and apical segments (Figure 6), and (6) bilateral pulmonary edema in T2-weighted morphology images ( Figure 4C and 4D). A diagnosis of aortitis and acute myocardial infarction was made.A significant rise of troponin (9.72 U/L), myoglobin (485 U/L), creatinine-kinase (6748 U/L), leukocyte count (14.2 10 9 /L), and protein-C (15.8 mg/dL) was evident. The patient was given aspirin, angiotensin converting enzyme inhibitors, ␤-blockers, and prednisone at a 50-mg daily dose. After normalization of inflammation indexes, 2 weeks after admission, coronary angiography showed left main occlusion, ostial right coronary artery stenosis (Movie IV of the onlineonly Data Supplement), and the left anterior descending artery perfused by collaterals from the right coronary artery ( Figure 7 and Movie V of the online-only Data Supplement). Echocardiography and cardiac magnetic resonance imaging showed improvement of left ventricular function (41%) and a large subendocardial infarction of the left anterior descending artery territory. Inasmuch as the transmural extent of the infarct was less than 50%, it was considered that substantia...

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