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Ann Thorac Surg 2007;83:1879-1881
© 2007 The Society of Thoracic Surgeons

Case Reports

Staged Therapeutic Approach in Spontaneous Coronary Dissection

Siamak Aliyary, MDa, Massimo A. Mariani, MD, PhDb, Patrick M.J. Verhorst, MD, PhDa, Marc Hartmann, MDa, Martin G. Stoel, MDa, Clemens von Birgelen, MD, PhDa,*

a Department of Cardiology, Medisch Spectrum Twente, Enschede, the Netherlands
b Department of Cardiac Surgery, Medisch Spectrum Twente, Enschede, the Netherlands

Accepted for publication November 28, 2006.

* Address correspondence to Dr von Birgelen, Medisch Spectrum Twente, Thoraxcenter Twente, Department of Cardiology, Haaksbergerstraat 55, Enschede, 7513ER the Netherlands (Email: von.birgelen{at}12move.nl).


   Abstract
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 Abstract
Introduction
 Comment
 References
 
Spontaneous coronary artery dissection is an extremely rare event occurring especially in pregnant women, either peripartum or postpartum. Urgent coronary angiography has to be performed to confirm the diagnosis and to determine the appropriate therapeutic strategy. We present the case of a 36-year-old woman in week 36 of her pregnancy who was admitted in cardiogenic shock due to an acute anterolateral myocardial infarction as a result of spontaneous coronary artery dissection. While she was on aortic balloon counterpulsation the patient underwent a cesarean section and gave birth to a healthy child. Subsequently she successfully underwent off-pump coronary artery bypass surgery.


   Introduction
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 Abstract
 Introduction
Comment
 References
 
Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndromes [1–5]. Spontaneous coronary artery dissection is strongly associated with pregnancy, both in peripartum and postpartum state, and mainly involves the left main stem or the left anterior descending artery, or both [1–5]. Urgent coronary angiography is indicated to establish the diagnosis and determine the appropriate therapeutic approach [2, 4]. Conservative medical strategy and revascularization procedures (either percutaneous or surgical) have been applied. However the optimal therapy has not yet been determined [2]. We present the clinical course, angiographic short-term follow-up, and surgical treatment of a young woman in advanced pregnancy who was admitted in cardiogenic shock due to an acute anterolateral myocardial infarction.

A 36-year-old woman in gestational week 36 of her pregnancy suddenly had severe chest pain develop associated with a short moment of collapse. She had no cardiac risk factors and no history of cardiac or connective tissue disease. On admission the patient was in cardiogenic shock (blood pressure 85/40 mm Hg, heart rate 116 bpm) with normal findings at cardiopulmonary auscultation. The electrocardiogram showed sinus rhythm and ST-elevation in leads I, aVL, and V1–V6 with reciprocal ST-depression in leads II, III, and aVF as signs of an acute anterolateral myocardial infarction. Transthoracic echocardiography showed an impaired left ventricular function (ejection fraction 30%; akinesia anterior and hypokinesia of the lateral, apical, and septal segments).

Emergency coronary angiography (Fig 1) showed a dissection of the proximal left anterior descending artery and slight lumen narrowing of the proximal circumflex artery without evidence of a dissection. The patient was treated with intraaortic balloon counterpulsation, enoxaparin subcutaneously, aspirin orally, and intravenous nitrates. As coronary blood flow distal to the SCAD was fully restored, we did not see an indication for direct revascularization in this near-term patient.


Figure 1
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  		Fig 1. Panels A–C: Initial coronary angiography showed a normal right coronary artery (RCA) (A), a dissection of the left anterior descending artery (LAD) proximal of the first septal branch with occlusion of a diagonal branch (B, C), and only a slight lumen narrowing of the proximal left circumflex artery (LCX) without evidence of a dissection membrane in the LCX (B, C). Panels D–F: Short-term angiographic follow-up after cesarean section showed no change in the RCA (D), but antegrade propagation of the dissection into the mid-LAD with occlusion of several septal branches (E, F) and development of small collaterals from the RCA (D; arrow). In addition, the retrograde spiral dissection through the main stem into the mid-LCX had become worse and resulted in significant lumen narrowing of the LCX (E, F).

 
Because of fetal distress, an emergency cesarean section was performed with support of intraaortic balloon counterpulsation. Under this intensive therapeutic regimen, a healthy child was born. Serum creatine kinase peaked at 7,270 µg/L (normal range, <170 µg/L), creatine kinase-MB was >300 µg/L (normal range, 0.6–6.3 µg/L), and cardiac troponin I was >100 µg/L (normal range, <0.03 µg/L).

During the first weeks after the cesarean section we favored conservative treatment to permit healing of the coronary vessels and because the patient was bleeding slightly but constantly from the uterus, requiring transfusions. We aimed at performing a control angiography after 2 weeks to determine a further therapeutic approach, but the patient suffered from slight postnatal and posttraumatic depression, and in the beginning she refused both a repeat coronary angiography and any revascularization therapy. During that period the patient suffered from recurrent chest pain with brief dynamic electrocardiographic ST-segment depression, but she remained hemodynamically stable and did not require aortic balloon counterpulsation or catecholamines. Transthoracic echocardiography showed slight improvement of her left ventricular function (ejection fraction, 40%; akinesia anterior and distal inferior) and dilatation of the apex.

Three weeks after the cesarean section, repeat coronary angiography could be performed, and it showed progression of the SCAD (Fig 1). There was an antegrade propagation of the dissection into the mid left anterior descending artery and evident worsening of the dissection through the main stem into the mid circumflex artery. After the angiography was finished we introduced an intraaortic balloon for counterpulsation as a precaution.

Several hours later, off-pump coronary artery bypass surgery was performed with temporary aortic balloon counterpulsation as a supporting measure. The left anterior descending artery and the obtuse marginal branch of the circumflex artery were revascularized using right and left mammary arteries. Postoperatively the patient remained hemodynamically stable and made an uneventful recovery, with an echocardiography showing significant improvement. Four weeks after the initial presentation, the patient was discharged home after another echocardiography with a left ventricular ejection fraction of 50%.

At the patient’s 6-month follow-up she showed a complete recovery of her physical condition and remained completely asymptomatic under medical therapy consisting of carvedilol, spironolactone, furosemide, and oral anticoagulation.


   Comment
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 Abstract
 Introduction
 Comment
References
 
Spontaneous coronary artery dissection in the absence of atherosclerosis is a rare disease. It was most often described in otherwise healthy, young women, mostly near term or within 3 months postpartum [1, 4, 5]. During pregnancy, SCAD is believed to be related to an altered endocrine status. Progesterone excess may cause structural changes to the vessel wall resulting in a greater propensity for dissections [1–7]; these changes include fragmentation of reticulin fibers, hypertrophy of smooth muscles, and loosening of ground substance [2, 4, 5]. Other experts see a causal role for eosinophilic inflammatory infiltrates [8]. Increased hemodynamic strain during pregnancy and delivery can start a small disruption of the intima, which may then lead to SCAD.

Women with SCAD frequently present with involvement of the left anterior descending artery or left main coronary arteries, or both, and require urgent coronary angiography to establish the diagnosis and determine the therapeutic strategy [2, 4]. After surviving the initial event, all modalities of treatment, including medical therapy, angioplasty, cardiac surgery, and even heart transplantation have been applied [1–7]. The choice of the appropriate therapy is primarily based on the clinical presentation, the extent of the dissection, and the amount of myocardium at risk [1–5]. We believe that patients with a non-occlusive dissection and normal antegrade coronary flow can be conservatively managed. Surgical intervention is indicated in cases with propagation of the SCAD or luminal narrowing (or both) that results in myocardial ischemia with significant hemodynamic compromise [4, 5].

In case of surgery, an off-pump approach with arterial grafts and use of less heparin should be preferred to reduce the risk of uterine bleeding and to maximize long-term results in this young population. We believe that SCAD requiring cesarean section with support of an aortic counterpulsation has not yet been described. The successful outcome of mother and child is encouraging and underlines the importance of an aggressive and flexible multidisciplinary approach to both diagnosis and treatment of patients with SCAD.


   References
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 Abstract
 Introduction
 Comment
 References
 

  1. Bac DJ, Lotgering FK, Verkaaik APK, Deckers JW. Spontaneous coronary artery dissection during pregnancy and post partum Eur Heart J 1995;16:136-138.[Abstract/Free Full Text]
  2. Almeda F, Barkatullah S, Kavinsky CJ. Spontaneous coronary artery dissection Clin Cardiol 2004;27:377-380.[Medline]
  3. Rensing BJ, Kofflard M, van den Brand MJBM, Foley D. Spontaneous dissection of all three coronary arteries in a 33-week-pregnant woman Cathet Cardiovasc Interv 1999;48:207-210.[Medline]
  4. Koul AK, Hollander G, Moskovits N, Frankel R, Herrera L, Shani J. Coronary artery dissection during pregnancy and the postpartum period: Two case reports and review of literature Cathet Cardiovasc Interv 2001;52:88-94.[Medline]
  5. Klutstein MW, Tzivoni D, Bitran D, Mendzelevski B, IIan M, Almagor Y. Treatment of spontaneous coronary artery dissection: report of three cases Cathet Cardiovasc Diagn 1997;40:372-376.[Medline]
  6. Bonnet J, Aumailley M, Thomas D, Grosgogeat Y, Broustet JP, Bricaud H. Spontaneous coronary artery dissection: case report and evidence for a defect in collagen metabolism Eur Heart J 1986;7:904-909.[Abstract/Free Full Text]
  7. Engelman DT, Thayer J, Derossi J, Scheinerman J, Brown L. Pregnancy related coronary artery dissection: a case report and collective review Conn Med 1993;57:135-139.[Medline]
  8. Sage MD, Koelmeyer TD, Smeeton WM. Fatal postpartum coronary artery dissection, a light- and electron-microscope study Am J Forensic Med Pathol 1986;7:107-111.[Medline]



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