Case Description

A 31-year-old gravida 2 para woman at 36 weeks of gestation and past preeclampsia presented to the hospital after acute onset of substernal chest pain. An initial electrocardiogram showed ST elevations in leads V ₁ –V ₄ , I, and aVL. Her initial heart rate was 127 beats/min, but she was not in shock. The initial cardiac troponin I was 4.01 ng/ml. An urgent coronary angiography disclosed total occlusion of the proximal left anterior descending (LAD) coronary artery and the appearance suggested coronary artery dissection. The left circumflex and right coronary arteries were angiographically normal. The LAD lesion narrowing was crossed with a wire, followed by insertion of intra-arterial balloon pump for cardiogenic shock. The obstetrics team performed an ultrasound of the fetus, and it showed bradycardia. An emergent cesarean section was performed in the cardiac catheterization laboratory, and a healthy baby was delivered. Multiple attempts at balloon angioplasty of the LAD were unsuccessful. As a consequence, emergency coronary artery bypass grafting (CABG) was performed. Intraoperative findings showed dissection of the LAD extending retrograde into the left main and into the left circumflex artery. The patient received 2 saphenous vein grafts to an obtuse marginal branch and 1 to the LAD. Postoperatively, the patient’s cardiogenic shock resolved. An echocardiogram showed severe left ventricular dysfunction with an ejection fraction of 10% to 15%. The patient and healthy baby were discharged after a 15-day stay in the hospital in stable condition. As an outpatient, her functional status remained excellent (New York Heart Association class I to II). A single chamber implantable cardioverter–defibrillator was placed after repeat echocardiogram at 4 months showed persistently severe left ventricular dysfunction despite maximally tolerated medical management.