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Ann Thorac Surg 2002;73:1324-1326
© 2002 The Society of Thoracic Surgeons

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Case report

Spontaneous coronary artery dissection presenting as cardiac tamponade

^a Department of Cardiac Surgery, Royal Victoria Hospital, Belfast, Northern Ireland
^b Regional Medical Cardiology Centre, Royal Victoria Hospital, Belfast, Northern Ireland

Accepted for publication August 2, 2001.

* Address reprint requests to Dr Badmanaban, Department of Cardiac Surgery, Royal Victoria Hospital, Grosvenor Rd, Belfast BT12 6BA, Northern Ireland
e-mail: balaji{at}talk21.com

	Abstract

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Spontaneous dissection of the left main coronary artery is the least common of all dissections involving the coronary arteries. It usually occurs in young women, especially in the peripartum or early postpartum period. We describe the case of a 59-year-old man with no previous history of atherosclerotic heart disease who presented in cardiac tamponade and was found to have a spontaneous left main stem coronary artery dissection at cardiac catheterization. Emergency revascularization was carried out with the patient remaining symptom-free 4 months after surgery.

	Introduction

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Spontaneous coronary artery dissection is a rare cause of ischemic heart disease and sudden death, with a mortality exceeding 80%. Risk factors for artherosclerosis are usually absent. Most of the known cases have been diagnosed at autopsy; few cases documented by angiography and successful operative cases have been reported.

A 59-year-old male power station worker with no previous history of ischemic heart disease presented to our teaching hospital’s emergency department in extremis. He had developed sudden onset of chest pain radiating to his legs approximately 1 hour previously. He was hypotensive, tachycardic, and diaphoretic. His neck veins were not noted to be distended.

Electrocardiography demonstrated sinus tachycardia without evidence of myocardial ischemia. Ultrasound examination of the abdomen was undertaken to exclude a ruptured abdominal aortic aneurysm and was normal. There was a lactic acidosis with blood pH at 7.16 and a base deficit of 16.5 mmol/L. Computed tomography of the thorax excluded thoracic aortic dissection but demonstrated a significant pericardial effusion. No invading extrapericardial lesion was seen. A transthoracic echocardiogram (Fig 1) confirmed the presence of a pericardial effusion containing echodense material with evidence of right ventricular diastolic collapse. Transesophageal echocardiography confirmed previous findings. The patient was transferred to the cardiac catheterization laboratory. A pericardial effusion with marked pulsus paradoxus was noted. Fluoroscopic pericardiocentesis was unsuccessful due to the solid nature of the effusion. Coronary angiography demonstrated dissection of the left anterior descending and circumflex arteries (Fig 2). The left main coronary artery was involved by implication. Angiographically, the coronary arteries appeared relatively free from atherosclerotic occlusive disease.

View larger version (126K): [in this window] [in a new window]   Fig 1. A pericardial effusion (E) containing echodense material is clearly evident in the subcostal view. (LV = left ventricle; RV = right ventricle.)

View larger version (179K): [in this window] [in a new window]   Fig 2. A differential contrast appearance is seen within the lumina of the left circumflex (solid arrow) and left anterior descending arteries (open arrows) in the lateral view, betraying underlying dissection of these vessels.

On the 6th postoperative day, the patient had an episode of syncope associated with melena. Upper gastrointestinal endoscopy revealed an ulcer in the posterior wall of the second part of the duodenum, which was injected with adrenaline, and helicobacter eradication started. Aspirin was withheld and clopidogrel was later introduced. Follow-up echocardiography at 2 weeks showed good left ventricular function with no residual pericardial effusion. There was no recurrence of melena.

	Comment

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Spontaneous intimal dissection is seen infrequently in arteries outside of the aorta. When it does occur, the coronary, renal, and carotid arteries are affected with similar frequency, and dissection is extremely rare at any other site [1]. Coronary artery dissection is therefore usually a secondary phenomenon, complicating coronary angiography and angioplasty, aortic dissection, prosthetic valve replacement, coronary artery bypass grafting, or blunt chest trauma [2]. Spontaneous coronary artery dissection was first described by Pretty in 1931. Such dissections most commonly occur in young healthy women [3]. Thayer and colleagues, in 1987, [3] reported that 79% were women with an average of 41 years in a comprehensive literature review. About one-third of cases occurred during or following pregnancy [4].

Spontaneous coronary dissection is also associated with angiitis, sarcoidosis, Marfan’s syndrome, and previous renal transplantation [5]. Cystic medial necrosis has been documented in some patients [2]. The left anterior descending, right coronary, circumflex, and left main coronary arteries are involved with decreasing frequency, respectively [6].

In contrast to aortic dissection, hypertension is not a risk factor, and the primary site of coronary wall dissection is usually the outer third of the tunica media or between the tunica media and the external elastic lamina [5]. Hemorrhage into the coronary wall is postulated to initiate dissection with luminal compromise by the expanding hematoma. Intimal tears representing a starting point for dissection are rarely identified [6]. Various changes in the coronary vessel wall and vasa vasorum as found in pregnancy probably contribute to pathogenesis [6].

A significant number of patients die suddenly [3]. Patients who survive to reach hospital usually present with ischemic syndromes ranging from stable angina to acute myocardial infarction [2]. The diagnosis is difficult to make, and many cases are identified at autopsy; a high degree of clinical suspicion in the typical patient, grouped together with early angiography, is required. Optimal patient management is not yet defined. Anticoagulants, anti-platelets, or thrombolytic therapy may worsen the dissection [2]. Patients who are managed conservatively often have a suboptimal outcome with survivors progressing to subsequent myocardial infarction, sudden death, or disabling angina [4].

Percutaneous coronary artery stenting is the treatment of choice for suitable dissections following angioplasty and has been successfully undertaken for spontaneous dissections, including those with multivessel involvement. Surgery was the preferred option in our case because of the need for evacuation of hemopericardium, lesion morphology with left main involvement, and arterial rupture.

The aim of surgery is to restore blood flow to the compromised myocardium and prevent propagation of the dissection [4]. The preferred conduit in an elective process is the internal mammary artery because of its long-term patency [4], but in our case, because of the time constraints, saphenous vein grafts were used.

Our case is unusual in that a patient of atypical profile presented not with myocardial ischemia but with cardiac tamponade. It is also important to note that further bleeding was arrested following grafting and repair of the dissection. This association has only been described in 1 other patient in the literature [1]. It is probable that the hematoma dissected through the wall of the artery resulting in free rupture and hemopericardium, rather than accumulating intramurally and compressing the vessel lumen. This case represents a rare survivor following surgery for a coronary artery dissection presenting as cardiac tamponade.

	References

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1. Cheung A., Chan C.W. Dissecting aneurysm of the coronary artery presenting as cardiac tamponade. N Z Med J 1990;103:129-130.[Medline]
2. Kearney P., Singh H., Hutter J., Khan S., Lee G., Lucey J. Spontaneous coronary artery dissection: a report of three cases and review of the literature. Postgrad Med J 1993;69:940-945.[Abstract/Free Full Text]
3. Thayer J.O., Healy R.W., Maggs P.R. Spontaneous coronary artery dissection. Ann Thorac Surg 1987;44:97-102.[Abstract/Free Full Text]
4. Alvarez J., Deal C.W. Spontaneous dissection of the left main coronary artery: case report and review of the literature. Aust N Z J Med 1991;21:891-892.[Medline]
5. Bateman A.C., Gallagher P.J., Vincenti A.C. Sudden death from coronary artery dissection. Ann Pathol 1995;48:781-784.
6. Thistlethwaite P.A., Trazi R.Y., Giordano F.J., Jamieson S.W. Surgical management of spontaneous left main coronary artery dissection. Ann Thorac Surg 1998;66:258-260.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Badmanaban, B. Articles by Sarsam, M. A.I. Search for Related Content PubMed PubMed Citation Articles by Badmanaban, B. Articles by Sarsam, M. A.I. Related Collections Coronary disease