Abstract
Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome. Knowledge of this condition is scarce and, at present, no consensus exists with regards to the aetiology, prognosis, and treatment.
Among patients with SCAD, cases involving the left main (LM) and the left anterior descending (LAD) and circumflex (Cx) arteries bifurcation are even more exceptional. Furthermore, the treatment of asymptomatic patients with involvement of these major vessels poses a major challenge for the cardiologists and cardiac surgeons.
We report a case of complicated spontaneous left main coronary artery dissection in which we question what is the best initial treatment in these asymptomatic patients: conservative or early aggressive.
1
Introduction
Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome (ACS) . Knowledge of this condition is scarce and, at present, no consensus exists with regards to the aetiology, prognosis, and treatment .
The management of asymptomatic patients with involvement of left main (LM) or major vessels poses a major challenge for cardiologists and cardiac surgeons.
We report a case of complicated spontaneous LM dissection in which we question what is the best initial treatment in these asymptomatic patients: conservative or early aggressive.
2
Case report
A 37 year-old woman was admitted with a two hours history of resting angina. She had no risk factors apart from hyperlipidemia. There was no other relevant medical history.
On arrival, her vital signs were stable. Initial electrocardiogram revealed ST-segment elevation in leads I-aVL.
Immediate coronary angiography (CA) demonstrated a smooth narrowing from LM extending to the bifurcation of anterior descending (LAD) and circumflex artery (Cx) ( Fig. 1 A ). This narrowing remained unchanged following intracoronary vasodilators. These vessels showed TIMI-3 flow. Right coronary artery was normal. The first diagonal branch, occluded initially, recovered its flow during the procedure and ST-elevation and symptoms disappeared. Suspecting intracoronary hematoma, we managed conservatively and planned reevaluation with intravascular ultrasound (IVUS) few days later.
The patient remained stable, maximum CPK was 4000 ng/ml and the echocardiogram showed lateral akinesia and moderate ventricular dysfunction.
CT-angiography (CTa), performed a week later, revealed no significant abnormalities ( Fig. 2 A ). To confirm this finding, a second CA with IVUS was performed eleven days later. After the first contrast injection, a spiral dissection was detected originating from the LM ostium towards LAD and Cx ( Fig. 1 B), with subsequent loss of flow in the latter and hemodynamic impairment. Emergent percutaneous coronary intervention (PCI) was performed. Direct paclitaxel-eluting stent (DES) was implanted at LM ostium (4,5×12 mm). Although hemodynamic status improved, LAD and Cx dissection remained, so we treated the bifurcation with Kissing stenting (paclitaxel-eluting stents: 3,5 × 32 mm in LAD; 3,5 × 28 mm in Cx) ( Fig. 2 B).
She evolved favorably with minimal enzyme elevation and similar echocardiographic situation and was discharged with aspirin, prasugrel, beta-blockers, ACE-inhibitors and statins. Two years later, she remains asymptomatic.
2
Case report
A 37 year-old woman was admitted with a two hours history of resting angina. She had no risk factors apart from hyperlipidemia. There was no other relevant medical history.
On arrival, her vital signs were stable. Initial electrocardiogram revealed ST-segment elevation in leads I-aVL.
Immediate coronary angiography (CA) demonstrated a smooth narrowing from LM extending to the bifurcation of anterior descending (LAD) and circumflex artery (Cx) ( Fig. 1 A ). This narrowing remained unchanged following intracoronary vasodilators. These vessels showed TIMI-3 flow. Right coronary artery was normal. The first diagonal branch, occluded initially, recovered its flow during the procedure and ST-elevation and symptoms disappeared. Suspecting intracoronary hematoma, we managed conservatively and planned reevaluation with intravascular ultrasound (IVUS) few days later.
