2.1

Case 1

The patient is a 36-year-old female with a past medical history of Yacoub–David intervention for the treatment of a chronic aortic dissection 5 years ago. The procedure was complicated by an inferior myocardial infarction with a residual inferior wall ectasia. No coronary angiogram was performed at the time. This patient presented an intense acute mediothoracic pain. First, electrocardiogram (ECG) did not show any ischemic signs. Aortic computed tomography (CT) scan showed no dissection of the aorta. In the cardiac care unit, the patient suffered again, and the ECG highlighted a transitory anterior ST elevation. The coronary angiogram overviewed a dissection of mid-left anterior descending coronary artery (LAD) with a Thrombolysis in Myocardial Infarction (TIMI) 3 flow. We opted for medical treatment because the coronary flow was not impaired and the dissection line was extended to the distal LAD. As symptoms receded, ECG normalized. Close medical follow-up was done and was event-free. The control CT scan at day 9 showed a circumferential hematoma at the level of the mid-LAD wall secondary to the dissection with a residual stenosis less than 50%, and the patient continue to be treated medically.

2.2

Case 2

A 30-year-old woman presented with an anterior ST-elevation myocardial infarction (STEMI) 14 days after a gemellar delivery. Her only treatment was bromocriptine. We performed urgent coronary angiogram that revealed dissection of left main coronary artery extending to LAD but with a conserved TIMI 3 flow ( Fig. 1 A ). As chest pain was fading away and ECG was normalized, the operator opted for a conservative strategy with a close follow-up in the intensive care unit. Five days later, a recurrence of the angina led to a second coronary angiography that showed an underperfused and vasoconstricted left coronary system ( Fig. 1 B). The patient presented a cardiogenic shock and was assisted by an intraaortic balloon pump (IABP) and transferred to the operating room for an urgent coronary artery bypass graft (left internal mammary artery to LAD, right internal mammary artery to left circumflex, and saphenous vein to bisector).

Coronary angiogram of patient 2 showing: a dissection of the left main coronary (arrow) artery with a conserved TIMI 3 flow (A); an extension of the dissection 5 days later with underperfused and vasoconstricted left coronary system (B).

2.3

Case 3

A 27-year-old woman with a history of untreated Raynaud syndrome was hospitalized for an inferior STEMI at 1 month postpartum. The emergent coronary angiogram showed an abrupt occlusion ( Fig. 2 A ) of mid-right coronary artery (RCA). We decided to perform PCI with stenting of the culprit lesion. The advancement of the guide wire was difficult; then we crossed the lesion with a microcatheter (Progreat 2.4-Fr 130-cm Microcatheter, Terumo) that was seated distally which allowed us to highlight the dissection and to confirm that the guide wire was in the true lumen ( Fig. 2 B). Two stents were deployed (Promus Element 2.5 mm×38 mm and Promus Element 2.5 mm×38 mm, Boston Scientific), but the distal RCA had a persisting TIMI 0 flow at the end of the procedure, probably explained by a distal extension of the coronary dissection ( Fig. 2 C). One month later, a treadmill stress test was performed under beta-blockers and was negative. A control coronary angiogram at 2 months showed no line of dissection. The proximal RCA had a stenosis of less than 50% and distal RCA presented a 90% stenosis on a small vessel (<2 mm) with TIMI 3 flow ( Fig. 2 D), so we decided to continue medical treatment.

Coronary angiogram of the patient 3 showing: an occlusion of the mid-RCA with a dissection line (A); the crossing of a microcatheter distally confirming that the guide wire was in the true lumen (B); the final result after stenting of the mid-RCA with persisting TIMI 0 flow on the distal part of the RCA (C); the control at 2 months showing TIMI 3 flow with a significant stenosis of the distal RCA on a small vessel (D).

2.4

Case 4

A 40-year-old woman presented a chest pain 6 months after delivery. The ECG showed anterior ST-segment elevation. The emergent coronary angiogram showed an occlusion of the LAD at its ostium. After further contrast injections, the LAD spontaneously unclogged, unmasking a dissection line extending to the left main coronary artery and the circumflex coronary artery. TIMI flow was 3 at the end of the exam. As coronary flow was spontaneously restored, medical treatment was continued. An IABP was implanted to bail out. One week later, while the patient was asymptomatic, the control coronary angiogram showed regression of the LAD dissection line with a TIMI 3 flow. The lesions of left main coronary artery and left circumflex artery remained unchanged. Four months later, another control of the coronary angiogram showed stable lesions without significant residual stenosis and a normal TIMI flow. The left ventricular ejection fraction improved to 60%.

The characteristics of our patients are presented in Table 1 . Except for patient 2, all patients were event-free at follow-up.

Table 1

Patients’ characteristics and individual initial treatments.

	Patient 1	Patient 2	Patient 3	Patient 4
Age	36	30	27	40
Sex	Female	Female	Female	Female
Risk factors
Familial history	No	No	Yes	No
Hypertension	No	No	No	No
Hypercholesterolemia	No	No	No	Yes
Diabetes mellitus	No	No	No	No
Smoking	No	Yes	No	No
Overweight	No	Yes	No	No
Suspected etiology	Marfan	Postpartum	Postpartum	Postpartum Vasospasm
Symptoms	Chest pain	Chest pain	Chest pain	Chest pain
ST-segment elevation	Yes	Yes	Yes	Yes
Initial LVEF (%)	39	61	65	40
Coronary involved	Mid-LAD	LM	Mid-RCA	LM
Fibrinolysis	No	No	No	No
Initial TIMI flow	3	3	0	3
Initial treatment	Medical	Medical	Stenting	Medical
Complications	No	Extension at follow-up	Distal TIMI 0 flow	No
Secondary treatment	No	CABG	Medical	No
Follow-up (years)	1	2	0.8	9

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