Ann Thorac Surg 2008;85:1793-1794. doi:10.1016/j.athoracsur.2007.11.018
© 2008 The Society of Thoracic Surgeons
Case Reports
Spontaneous Coronary Dissection in Late Pregnancy: A Multidisciplinary Approach to Management
Hisham M.F. Sherif, MDa,*,
Hiep C. Nguyen, MDa,
Brian H. Sarter, MDb,
Joseph T. West, MDb,
Edward Lucente, MDc,
David M. Fink, MDd,
Adrian Quesada-Rojas, MDd,
Michael K. Banbury, MDa
a Department of Cardiac Surgery, Christiana Hospital, Christiana Care Health System, Newark, Delaware
b Department of Cardiology, Christiana Hospital, Christiana Care Health System, Newark, Delaware
c Department of Cardiac Anesthesia, Christiana Hospital, Christiana Care Health System, Newark, Delaware
d Department of Obstetrics and Gynecology, Christiana Hospital, Christiana Care Health System, Newark, Delaware
Accepted for publication November 2, 2007.
* Address correspondence to Dr Sherif, Department of Cardiac Surgery, Christiana Hospital, Christiana Care Health System, 4755 Ogletown-Stanton Rd, Ste 1E50, Newark, DE 19718 (Email: hsherif{at}christianacare.org).
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Abstract
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Spontaneous coronary dissection is a rare but potentially life-threatening condition. It often occurs in late pregnancy and may pose significant risks for the patient and the fetus. Its cause remains uncertain, and established guidelines for management have not been developed. In this report, close multidisciplinary collaboration has led to excellent outcomes in this condition.
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Introduction
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Spontaneous coronary dissection in the absence of atherosclerosis is a rare finding. Such spontaneous dissection is most often encountered in fairly young [1, 2], otherwise healthy women, with about 30% of cases occurring in late pregnancy (near-term) or within 3 months postpartum [1–7]. Although still incompletely understood, several theories have been proposed, including the effect of altered endocrine status with progesterone excess, eosinophilic inflammatory infiltrates, and the increased hemodynamic strain of pregnancy [3–5, 8]. This condition affects most commonly the left main coronary artery, the left anterior descending artery, or both [1, 3, 4]. As such, this condition puts a significant portion of the left ventricle at jeopardy for acute, extensive ischemia or thrombosis/infarction, or both, which can precipitate severe hemodynamic compromise with a high risk of maternal and fetal adverse outcomes.
The patient is a 34-year-old woman who sustained a myocardial infarction (MI) in August 2001. She was previously documented to have normal coronary angiographic anatomy and depressed left ventricular systolic function (left ventricular ejection fraction, 0.35). Cardiovascular risk factors included obesity (weight, 100.8 kg; body mass index, 32.9), hypertension, type I diabetes mellitus, previous use of oral contraceptives, and continuing tobacco abuse.
The patient presented to the Christiana Hospital Emergency Department with acute, sharp, substernal chest pain, shortness of breath, and diaphoresis. Symptoms were similar to those during her prior MI. She denied previous paroxysmal nocturnal dyspnea or syncope. Vital signs on admission were stable (heart rate, 80 beats/min; blood pressure, 118/58 mm Hg) and she was afebrile. Results of laboratory tests were within normal limits except for cardiac enzymes, which were elevated (troponin-T, 0.97 ng/mL; creatine kinase-MB fraction, 34.5 ng/mL; creatine kinase-MB index of 7%).
Because the patient was 34 weeks pregnant at the time of presentation, she was initially triaged at the obstetrics (OB)/gynecology (GYN) area, where she was noted to have new electrocardiographic changes (ST elevation in leads I, V2, and aVL; ST depression in inferolateral leads) and ongoing chest tightness and discomfort. She was promptly referred to our well-established "Heart Code" acute coronary syndrome (ACS) emergency department pathway as a patient with ACS/ST elevation MI (ACS/STEMI).
An emergency cardiac catheterization revealed extensive coronary artery dissection involving the left main coronary artery and extending to involve two-thirds of each of the left anterior descending coronary artery and the left circumflex coronary artery (Fig 1) with thrombolysis in MI (TIMI) grade 2 flow in the distal segments of the affected vessels. The dominant right coronary artery was normal. Transthoracic and transesophageal echocardiography demonstrated no evidence of aortic dissection or significant valvular incompetence. The left ventricle was dilated and globally hypokinetic, with an ejection fraction estimated at 0.40. Vital signs and hemodynamics of both the patient and fetus continued to be stable.
An urgent deliberation between the cardiology, cardiac surgery, OB/GYN, and cardiac anesthesia team members then ensued. The main objectives were to safeguard the patient and her fetus in light of the stable hemodynamic status of the mother and excellent chance (100%) of fetal survival. Expectant medical therapy was ruled out because of the precarious status of the patient's coronary anatomy and the high risk for extensive coronary thrombosis, and so was vaginal delivery because of its undue stress on the already jeopardized myocardium. Insertion of an intraaortic balloon pump was avoided because of the stable hemodynamics and the decision to forgo expectant therapy, and also because of the risk of further extending the coronary dissection secondary to the increase of coronary perfusion.
To avoid the adverse effects of the general anesthetic agents or cardiopulmonary bypass, or both, on the fetus, the plan was to perform an emergency lower-segment caesarean section to deliver the fetus with simultaneous emergency coronary artery bypass grafting of the affected vessels. The clinical situation, risks, and benefits were thoroughly discussed with the patient and her family, who agreed to proceed with the proposed plan.
In the cardiac surgery operating room, the OB/GYN surgical team was scrubbed alongside the cardiac surgery team. With the patient on the operating table, and to minimize the effects of general anesthetic agents on the fetus, invasive monitoring catheters were placed under local anesthesia supplemented with systemic analgesia. The patient was prepared from chin to toes and draped from the waist down, and then endotracheally intubated and placed under general anesthesia. With the cardiac surgery team members standing by, an emergency lower-segment caesarean section was immediately performed. A viable female infant was delivered and transferred to the neonatal intensive care unit (ICU) for continuing recovery.
As soon as the abdominal incision was closed, the upper part of the patient was reprepared and draped. The cardiac surgery team used a full sternotomy, and the patient was placed on cardiopulmonary bypass. For the emergency coronary artery bypass grafting, the team used the left internal thoracic artery to the left anterior descending coronary artery and a reversed saphenous vein graft sequentially to the ramus intermedius and the obtuse marginal coronary arteries.
The patient tolerated both procedures well and was transferred to the cardiovascular ICU in a stable condition and without inotropic support. She was extubated on the night of the procedures, and left the ICU on the first postoperative day. Her postoperative course was uneventful, and she was discharged on postoperative day 5. The baby continues her recovery in the neonatal ICU.
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Comment
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Spontaneous coronary dissection is a rare occurrence, with incidence of 0.1% to 0.4%, but it still has a significant impact on maternal and fetal survival—estimated between 21% and 37%—with sudden death occurring frequently [1, 3]. The commonest clinical presentation is the ACS, with severity ranging from unstable angina to extensive acute MI and cardiogenic shock, depending on the size of the ventricular myocardium at risk. The diagnosis is often difficult to make and requires a high index of suspicion.
Because of the high risk associated with this condition to both the mother and the fetus, the management strategy often presents a challenge to the clinical team. Optimal patient management guidelines have not yet been established. Several strategies have been reported [1–8], including medical therapy, percutaneous coronary intervention, an emergency surgical procedure, and even heart transplantation [1].
In our case report, the objective of the managing physicians was to ensure the optimal outcome for both the mother and fetus. We attribute the positive outcome to:
- • The high index of suspicion by the emergency department triage physician leading to prompt activation of the ACS protocol and minimizing the time to confirm the diagnosis.
- • The close collaboration of the cardiology, OB/GYN, cardiac anesthesia, and cardiac surgical teams in planning the emergency surgical procedure and establishing their order of priority.
- • The smooth coordination of the surgical teams in performing two simultaneous complex procedures in such a high-risk situation.
- • In conclusion, despite the serious and often life-threatening nature of spontaneous coronary artery dissection during pregnancy, a well-coordinated collaborative strategy by all the clinicians involved in the patient's care should always be undertaken and can contribute to a positive outcome for the patient and the fetus.
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References
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Abstract
Introduction
