1.1

Case report

A 28-year-old woman in the 36th week of her second pregnancy suffered acute chest pain in the hours following psychological stress due to her grandfather’s death. She had no personal medical history, no cardiac risk factors, and her first pregnancy was free of any complications.

After admission within 2 h following the onset of chest pain, clinical examination was normal. Twelve-lead electrocardiogram (ECG) showed sinus rhythm with a QS pattern through leads V1 to V4 alternating with accelerated idioventricular rhythm. Troponin I levels were elevated at 26 ng/ml (normal <0.1 ng/ml). Transthoracic echocardiography showed left ventricular (LV) systolic dysfunction with depressed ejection fraction at 40% and an anteroseptoapical akinesia. The diagnosis of Takotsubo cardiomyopathy was initially hypothesized. A coronary angiography was not immediately performed because the patient remained asymptomatic and because of risks for pregnancy.

A cardiac magnetic resonance imaging (clinical 3-T ACHIEVA; Philips Medical Systems, Eindhoven, The Netherlands) without gadolinium injection was then performed on Day 5. The T2-weighted spin echo sequences revealed isolated apical akinesia associated with an anterior and apical edema excluding the initial hypothesis ( Fig. 1 ).

Cardiac magnetic resonance imaging in T2-weighted spin echo sequences in short (A) and long axis (B), showing an anterior and apical edema (arrows).

The diagnosis of SCAD was then considered. In order to assess the coronary risk of delivery, a coronary angiography by left radial approach, using a 6F Judkins left catheter (Medtronic, Minneapolis, MN, USA), was performed highlighting a radiolucent flap in the distal LAD consistent with a SCAD ( Fig. 2 ). Medical treatment was decided because the patient was asymptomatic and the SCAD limited to the distal LAD with a normal coronary flow [Thrombolysis in Myocardial Infarction (TIMI) 3]. Unfortunately, during the coronary catheterization, the patient experienced acute chest pain. Twelve-lead ECG showed major circumferential ST-segment elevation. Emergency coronary angiography showed a normal left main artery flow but highlighted a LAD and circumflex artery occlusion. A percutaneous coronary intervention (PCI) by right femoral approach was performed using a 5F Judkins left catheter (Medtronic) and restored a normal flow in the circumflex artery but failed to reperfuse LAD ( Fig. 3 ).

Coro-angiogram in right oblique anterior view (A) and transverse view (B) of LAD showing a dissection in the distal segment of the artery with a TIMI 3 flow.

Coro-angiogram of the left coronary arteries in right oblique anterior view showing LAD and circumflex arteries occlusion (A). A percutaneous coronary intervention was performed and restored a normal flow in the circumflex artery (B) but failed to reperfuse distal left anterior descending artery (C).

An emergency off-pump coronary artery bypass grafting (CABG) surgery was then performed. Both LAD and circumflex arteries were revascularised using left and right mammary arteries. Because of foetal suffering at the end of surgery, an emergency cesarean delivery was performed to give birth to a newborn with neonatal respiratory distress (Apgar score of 2 at 1 min) necessitating nasotracheal intubation and hospitalization in a paediatric intensive care unit.

Because of a depressed LV systolic function (LV ejection fraction of 15%) with a low cardiac output, a ventricular assist device [extracorporeal membrane oxygenation (ECMO)] was implanted, associated with inotropic support. Initial evolution was then favourable, with improvement of LV ejection fraction to 45% allowing the weaning of drug support and left ventricular assist device.

Two weeks later, echocardiography showed anterior akinesia with stable LV ejection fraction of 45%. The patient was placed on a regimen of antiplatelet agents, beta-adrenergic blocker, and angiotensin-converting enzyme inhibitor and has remained free of any cardiovascular complication within the 6 months following surgery, with improvement of LV ejection fraction to 60%.