Pregnancy-related spontaneous coronary artery dissection after intravenous ritodrine infusion: a case report / 世界急诊医学杂志（英文）

@#Ritodrine hydrochloride (ritodrine) is a β2-adrenoceptor stimulant that has been effectively prescribed for the prevention of premature labor.[1] In clinical practice, one of the biggest drawbacks of β-mimetics is their adverse effects, including arrhythmias, myocardial ischemia, and pulmonary edema, due to their β-sympathomimetic effects.[2] Here, we report a rare pregnant case of spontaneous coronary artery dissection (SCAD) after intravenous infusion of ritodrine.

Dissecção espontânea da artéria coronária, uma doença multifatorial: perspectivas da experiência de um centro / Spontaneous coronary artery dissection, a multifactorial disease: insights from a center experience

Introdução: Embora seja uma doença pouco conhecida, a dissecção espontânea da artéria coronária é uma causa importante e frequentemente subdiagnosticada da síndrome coronariana aguda não aterosclerótica, principalmente em mulheres. O objetivo deste estudo foi caracterizar uma amostra consecutiva de pacientes diagnosticados com dissecção espontânea da artéria coronária quanto a fatores predisponentes e desencadeadores; quadro clínico e angiográfico; abordagem terapêutica; ocorrência de eventos cardíacos adversos; recorrência e dissecção espontânea de artéria coronária de novo. Métodos: Estudo retrospectivo observacional longitudinal, unicêntrico, que incluiu pacientes diagnosticados com dissecção espontânea da artéria coronária (n=60) admitidos entre janeiro de 2010 e dezembro de 2020. Resultados: A mediana da idade foi de 55 anos, e 83% eram mulheres. A maioria dos pacientes (60%) não apresentava nenhum ou tinha apenas um fator de risco cardiovascular. O infarto agudo do miocárdio sem supradesnivelamento do segmento ST foi o quadro clínico em 67% dos casos. A artéria coronária mais frequentemente envolvida foi a descendente anterior (47%). A maioria das lesões (77%) aparecia na angiografia como dissecção espontânea da artéria coronária tipo 2. O tratamento conservador foi selecionado como abordagem inicial na maioria dos pacientes (72%). A incidência geral de dissecção espontânea da artéria coronária de novo não foi significativamente diferente entre os pacientes tratados primeiramente com revascularização, em comparação com os que receberam tratamento conservador (p=0,953). No entanto, a recidiva da dissecção espontânea da artéria coronária ocorreu no vaso originalmente envolvido em 3 dos 15 pacientes tratados com revascularização, em comparação com apenas um entre os 43 pacientes que foram tratados de forma conservadora (p<0,05). Conclusão: A dissecção espontânea da artéria coronária é mais frequente em mulheres jovens. O infarto agudo do miocárdio sem supradesnivelamento do segmento ST foi o quadro clínico mais observado, envolvendo principalmente a artéria descendente anterior. A revascularização não protegeu da recorrência.

Background: Although it is a poorly known disease, spontaneous coronary artery dissection is an important and frequently underdiagnosed cause of non-atherosclerotic acute coronary syndrome, particularly in women. The objective of this study was to characterize a consecutive sample of patients diagnosed with spontaneous coronary artery dissection with respect to predisposing and precipitating factors; clinical and angiographic presentation; management; occurrence of adverse cardiac events; recurrence; and de novo spontaneous coronary artery dissection. Methods: Longitudinal, observational, retrospective, single-centre study, including patients diagnosed with spontaneous coronary artery dissection (n=60) admitted between January 2010 and December 2020. Results: Median age was 55 years, and 83% were women. Most patients (60%) presented without any or just one cardiovascular risk factor. Non-ST-segment elevation acute myocardial infarction accounted for 67% of clinical presentations. The most frequently affected coronary artery was the left anterior descending (47%). Most lesions (77%) appeared on angiography as type 2 spontaneous coronary artery dissection. Conservative management was chosen as the initial approach in most patients (72%). The overall incidence of de novo spontaneous coronary artery dissection was not significantly different among patients initially managed with revascularization as compared to conservative treatment (p=0.953). However, spontaneous coronary artery dissection recurrence occurred in the originally involved vessel in 3 of 15 patients initially managed with revascularization, as compared to only one among 43 patients treated conservatively (p<0.05). Conclusion: Spontaneous coronary artery dissection occurs more often in young women. Non- ST-segment elevation acute myocardial infarction was the most frequent clinical presentation involving mainly the left anterior descending artery. Revascularization did not protect from recurrence.

Pregnancy-Associated Spontaneous Coronary Artery Dissection: A Case Report and the Lessons from Practice

@#Pregnancy-associated spontaneous coronary artery dissection (P-SCAD) is one of the fatal conditions that most commonly causes pregnancy-associated myocardial infarction. We herein report a case of P-SCAD in a 26-year-old multigravida woman, who complained of angina postpartum with raised cardiac biomarkers and transient ST-segment elevation on electrocardiograms. We emphasize the importance of a high degree of suspicion in the diagnosis of P-SCAD, together with the common presentation, the management approach, and its psychological impacts on the patients.

Disección espontánea de la arteria coronaria e infarto agudo de miocardio / Spontaneous coronary artery dissection and acute myocardial infarction

Resumen La disección espontánea de la arteria coronaria es una causa no aterosclerótica de infarto de miocardio, la cual es más común en mujeres jóvenes con pocos o ningún factor de riesgo cardiovascular. Es infrecuente, no se asocia a iatrogenia ni trauma, y se presenta por acumulación espontánea de sangre entre las capas de la pared arterial coronaria, por ruptura de la íntima; de ahí que genera una falsa luz que produce compresión externa del verdadero lumen arterial, con lo cual altera el flujo sanguíneo coronario y ocluye la arteria comprometida. Se expone el caso de una mujer de 31 años, sin factores de riesgo cardiovascular, quien ingresó a un servicio de urgencias con dolor torácico típico, de 2 horas de evolución. En el electrocardiograma se apreció elevación del segmento ST en las derivaciones de la cara anteroseptal e inferior, y troponina T de alta sensibilidad positiva, por lo que se realizó terapia trombolítica con tenecteplasa, sin obtener criterios de reperfusión. Se hizo angiografía coronaria, la cual mostró obstrucción total de la arteria coronaria descendente anterior en el tercio medio. El ultrasonido intravascular documentó flap de disección y hematoma en este segmento, los cuales confirmaron la disección coronaria espontánea. Se realizó angioplastia con implante de stent coronario y se restableció la circulación, observando mejoría de los síntomas.

Abstract Spontaneous coronary artery dissection is a non-atherosclerotic cause of myocardial infarction, more frequent in young women with few or no cardiovascular risk factors, it is infrequent, and it is not associated with iatrogenesis or trauma. It occurs due to spontaneous accumulation of blood between the layers of the coronary artery wall, due to rupture of the intima, generating a false lumen that produces external compression of the true arterial lumen, altering coronary blood flow, occluding the compromised artery. It is presented the case of a 31-year-old woman with no cardiovascular risk factors, who was admitted to an emergency department, with typical chest pain of 2 hours of evolution, showing ST-segment elevation in leads of anteroseptal and inferior face on the electrocardiogram and troponin T with high sensitivity positive. Therefore, thrombolytic therapy was performed with tenecteplase, without obtaining reperfusion criteria. Coronary angiography was performed that demonstrates total obstruction of the anterior descending coronary artery in the middle third. Intravascular ultrasound documents the dissection flap and hematoma in this segment that confirm spontaneous coronary dissection, performing angioplasty with implantation of a coronary stent, restoring circulation with improvement of symptoms.

Causa rara de parada cardíaca: um caso de extensa dissecção espontânea da artéria coronária esquerda / A rare cause of cardiac arrest: a case of an extensive left coronary artery spontaneous dissection

Um homem de 28 anos com história pregressa de abuso de drogas foi encaminhado para coronariografia de emergência após parada cardíaca. O eletrocardiograma pós-ressuscitação mostrou elevação do segmento ST em V1-V4. A angiografia mostrou dissecção espontânea da artéria coronária, multiarterial e em diversos segmentos. Devido à instabilidade clínica, o paciente foi submetido à intervenção coronária percutânea da artéria descendente anterior. A prevalência da dissecção espontânea da artéria coronária como causa de síndrome coronariana aguda em homens é infrequente. No entanto, nos casos suspeitos, ela deve ser excluída. A parada cardiorrespiratória é um quadro incomum na dissecção espontânea da artéria coronária, e a intervenção coronária percutânea como modalidade terapêutica ainda é uma questão em debate.

A 28-year-old male with a previous history of drug abuse was sent to an emergent coronary angiography, after a cardiac arrest, with a post-resuscitation eletrocardiogram showing ST- segment elevation from V1-V4. Angiography showed multivessel and multisegment spontaneous coronary artery dissection. Due to clinical instability, patient underwent left anterior descending artery percutaneous coronary intervention. Prevalence of spontaneous coronary artery dissection as the cause of acute coronary syndrome is anecdotal in men. Yet, in the right scenarios as in this case, it must be ruled out. Cardiorespiratory arrest is an uncommon presentation of spontaneous coronary artery dissection and percutaneous coronary intervention in spontaneous coronary artery dissection is still a matter of debate.

Dissecção espontânea da artéria coronária em gestação gemelar no terceiro trimestre: relato de caso / Spontaneous coronary artery dissection in a twin pregnancy in the third trimester: a case report

O infarto agudo do miocárdio no período gravídico-puerperal é uma condição rara em que a principal causa é a dissecção espontânea da artéria coronária. É um evento comumente subdiagnosticado, com pouca literatura disponível e elevado índice de morbimortalidade. Esse relato descreve o caso de uma gestante de 36 semanas de gravidez gemelar, monocoriônica-diamniótica, com infarto agudo do miocárdio secundário à dissecção espontânea da artéria coronária. As equipes de cirurgia cardíaca e obstetrícia optaram pela realização de parto cesariano e histerectomia subtotal, seguido da revascularização da artéria mamária descendente anterior. Discutem-se as orientações adotadas na dissecção espontânea da artéria coronária, bem como a abordagem terapêutica e a conduta obstétrica, quando essa condição ocorre durante a gravidez.(AU)

Acute myocardial infarction in the pregnancy-puerperal period is a rare condition the main cause of which is the spontaneous coronary artery dissection. A commonly underdiagnosed event with little available literature and a high rate of morbidity and mortality. This case reports a 36-week pregnant woman of mono-chorionic-diamniotic pregnancy who had a myocardial infarction secondary to a spontaneous coronary artery dissection. In a joint discussion between the team of cardiac surgery and obstetrics, it was decided to perform a cesarean delivery and subtotal hysterectomy followed by revascularization of the mammary anterior descendant. It discusses the conducts to be adopted in a case of spontaneous coronary artery dissection as well as therapeutic approaches and obstetric conducts to be taken in a case of dissection during pregnancy.(AU)

Disección coronaria espontánea / Spontaneous coronary artery dissection

Resumen La disección coronaria espontánea es la separación de capas de la pared de una arteria coronaria epicárdica secundaria a hemorragia intramural, con o sin desgarro de la íntima, no asociada con aterosclerosis, traumatismo o iatrogenia. Esta enfermedad ha emergido como causa de síndrome coronario agudo e infarto agudo de miocardio en personas jóvenes, principalmente mujeres, cuya prevalencia de factores de riesgo cardiovasculares es menor en comparación con el síndrome coronario agudo por aterosclerosis. Su diagnóstico se hace con síntomas clínicos, exclusión de causas secundarias, arteriografía coronaria y a veces, con la ayuda de imágenes intra o extravasculares. En la mayoría de los casos el manejo es conservador, con algunas excepciones en donde se requiere intervención percutánea o quirúrgica. Se presenta el caso de un paciente masculino de mediana edad con disección coronaria espontánea, quien se presentó con un infarto agudo de miocardio con elevación del segmento ST.

Abstract Spontaneous coronary dissection is the separation of layers of the wall of an epicardial coronary artery secondary to intramural bleeding, with or without tear of the intima, not associated with atherosclerosis, trauma or iatrogenia. This condition has emerged as a cause of acute coronary syndrome and acute myocardial infarction in young people, occurring mainly in women, whose prevalence of cardiovascular risk factors is lower compared to acute coronary syndrome due to atherosclerosis. Diagnosis is made with clinical symptoms, exclusion of secondary causes, coronary arteriography and, in some cases, the help of intra- or extravascular images is required. In most cases the management is conservative, with some exceptions where percutaneous or surgical intervention is required. We present the case of a middle-aged male with spontaneous coronary dissection, who presents with an acute myocardial infarction with ST segment elevation.

Infarto agudo al miocardio secundario a disección coronaria espontánea biarterial: reporte de un caso y revisión de literatura / Acute myocardial infarction due to spontaneous two vessel coronary artery dissection

Resumen: La disección coronaria espontánea ha surgido como una causa interesante y poco reconocida de síndrome coronario agudo no aterosclerótico. Ocurre más frecuentemente en mujeres jóvenes, donde de forma importante puede asociarse a anomalías arteriales no coronarias. La clave para un tratamiento oportuno es el diagnóstico precoz que impida su evolución a cuadros más severos. Se presenta el caso de una mujer de 36 años con un síndrome coronario agudo secundario a una disección coronaria espontánea bi-arterial que evolucionó de forma grave a una insuficiencia cardíaca aguda. El objetivo es informar un cuadro poco usual y proporcionar evidencia que respalde el cómo debe enfrentarse.

Abstract: Spontaneous coronary dissection is an important cause of acute non-atherosclerotic coronary syndrome. It occurs more frequently in young women, often without significantly associated coronary arterial anomalies. Early diagnosis is a key to prompt treatment, in order to prevent severe complications. We report the case of a 36-year-old woman with an acute coronary syndrome secondary to spontaneous bi-arterial coronary dissection progressing to severe acute heart failure. A discussion of the management of this condition is included.

Disección coronaria espontánea en paciente trasplantada de corazón / Spontaneous coronary artery dissection in a heart transplant patient: report of one case

Spontaneous coronary artery dissection is an uncommon cause of acute coronary syndrome that predominantly affects women without cardiovascular risk factors. In transplant patients, spontaneous coronary artery dissection is an extremely rare condition, having been described in only three patients, in whom vascular damage secondary to the use of anticalcineurinics is postulated as a probable mechanism. We report a spontaneous coronary dissection in a female who received a heart transplant at 34 years of age. The diagnosis was made in a follow-up coronary angiography three years after transplantation, supplemented with optical coherence tomography. A percutaneous coronary revascularization of the involved artery was performed, with good immediate results and at one year of follow-up.

Disección espontánea de arterias coronarias en una mujer embarazada / Spontaneous coronary artery dissection in a pregnant woman

Resumen La disección espontánea de las arterias coronarias representa entre 0,2 al 4% de las causas de síndrome coronario agudo, y es más común en mujeres jóvenes, especialmente en estado de embarazo, en cuyo caso el riesgo es tres a cuatro veces mayor. Usualmente, afecta la arteria coronaria izquierda pero también puede haber compromiso de múltiples vasos. Los pacientes que la presentan no tienen los factores de riesgo clásicos descritos de la enfermedad coronaria, como diabetes mellitus, hipertensión o dislipidemia. En las gestantes se puede presentar en cualquier trimestre del embarazo y hasta varios meses después del parto, pero es más común en el último trimestre del embarazo y en las primeras seis semanas posparto. El diagnóstico de disección de arteria coronaria es difícil; el estándar de oro es la coronariografía con ecografía intravascular o la tomografía de coherencia óptica; esta última no se encuentra ampliamente disponible. Además, existe controversia en cuanto a la decisión de manejo médico o manejo invasivo.

Abstract Spontaneous coronary artery dissection accounts for between 0.2% and 4% of the causes of acute coronary syndrome. It is more common in young women, particularly during pregnancy, when the risk is three to four times higher. It usually involves the left coronary, but it can also compromise several vessels. The patients that present with one do not have the classic risk factors described for coronary disease, such as diabetes mellitus, hypertension, or dyslipidaemia. Although it can present in any trimester of the pregnancy, and up to several months after delivery, it is more common in the last trimester of pregnancy, and in the first six months post-partum. The diagnosis of coronary artery dissection is difficult. Although the reference method is coronary angiography with intravascular ultrasound or optical coherence computed tomography, these are not widely available, as well as there being controversy as regards the decision of medical management or invasive management.

Infarto agudo do miocárdio por dissecção coronariana: relato de caso / Acute myocardial infarction by coronary dissection: case report

A dissecção espontânea da artéria coronária (DEAC) é uma importante causa de Síndrome Coronariana Aguda (SCA) não aterosclerótica. Frequentemente subdiagnosticada, sua etiologia e fisiopatologia permanecem incertas e seu manejo indefinido. Afeta geralmente mulheres jovens e sem os clássicos fatores de risco. Objetivo: relatar caso de DEAC e tratamento realizado. Método: as informações foram obtidas por meio de prontuário, entrevista, registro fotográfico e revisão de literatura. Resultados: paciente feminina, 42 anos, admitida na emergência de um hospital de referência em cardiologia do Oeste de SC, com história de dor torácica anginosa típica, durante período de estresse emocional. Apresentou eletrocardiograma (ECG) com diagnóstico de infarto agudo do miocárdio, elevação do segmento ST em parede anterior extensa (D1, AVL, V1-V6), elevação de marcadores de necrose miocárdica e coronariografia com aspecto de dissecção de artéria descendente anterior (ACDA). Optado por tratamento conservador devido a estabilidade hemodinâmica, apresentando melhora do quadro clínico e boa evolução no seguimento ambulatorial. Discussão: A DEAC é uma condição subdiagnosticada à apresentação normalmente é de SCA, sendo seu diagnóstico através da coronariografia. O manejo dessa condição continua incerto, vários fatores influenciam na estratégia de tratamento, como o quadro clínico, hemodinâmico, a topografia da dissecção, o número de artérias afetadas, o fluxo coronário distal e a disponibilidade de serviços de cardiologia intervencionista e cirurgia cardíaca. Considerações finais: diante de um caso de SCA em pacientes jovens, a suspeita diagnóstica de DEAC deve ser considerada. A confirmação diagnóstica depende da angiografia coronariana, e a terapêutica apesar de controversa deve ser individualizada.

The spontaneous coronary artery dissection (SCAD) is an important cause for acute coronary syndrome (ACS) non-atherosclerotic. Usually underdiagnosed, its etiology and pathophysiology remain uncertain and its management undefined. It usually affects young women without the classic risk factors. Objective: to describe a case of SCAD and the treatment applied. Method: the information was obtained through prontuary, interview, photographic register and literature review. Results: female pacient, 42 years old, admited to the emergency room of a reference hospital on cardiology in the west of Santa Catarina (SC), with a history of typical anginal thoracic pain, throughout period of emotional stress. Presented eletrocardiogram (ECG) with diagnosis of acute myocardial infarction, elevation of the ST segment in extensive anterior wall (D1, AVL, V1-V6), elevation of myocardial necrosis markers and coronary angiography with an aspect of anterior descending artery dissection (ACDA). Opted for a conservative treatment due to the hemodynamic stability, showing improvement of the clinical picture and good evolution in outpatient follow-up. Discussion: The SCAD is a condition normally underdiagnosed to ACS, being its diagnosis through coronary angiography. The management of this condition remain uncertain and many factors influence in the treatment strategy, as the clinical picture, the hemodynamic picture, the dissection topography, the number of affected arteries, the distal coronary flow and the availability of interventionist cardiology services and cardiac surgery. Final Considerations: in a case of ACS in young patients, the suspect diagnosis of SCAD must be considered. The diagnosed confirmation depends of coronary angiography, and the therapeutic, although controvertial, must be individualized.

Rol del ultrasonido intravascular en el diagnóstico de la disección coronaria espontánea / Role of intravascular ultrasound in the diagnosis of spontaneous coronary artery dissection / Papel da ultrassonografia intravascular no diagnóstico da dissecção espontânea das coronárias

Resumen: El diagnóstico de disección coronaria espontánea como causa de síndrome coronario agudo ha aumentado desde el surgimiento de las técnicas de imagen intracoronaria. Aún así, continúa siendo una entidad subdiagnosticada. La evidencia en relación con el tratamiento es escasa, pero la conducta conservadora ha demostrado resultados favorables en pacientes seleccionados. Presentamos el caso de una paciente de 55 años en la que se diagnostica infarto de miocardio sin elevación del ST. En la cineangiocoronariografía se sospecha como mecanismo causal la disección coronaria espontánea, lo cual se confirma mediante ultrasonido intravascular. Se optó por un tratamiento conservador con buena evolución.

Summary: The diagnosis of spontaneous coronary artery dissection as a cause of acute coronary syndrome has increased since the arise of intravascular imaging techniques. However, it still remains an underdiagnosed entity. Evidence related to its management is scarce, but conservative strategies have shown favorable outcomes in selected patients. We present the case of a 55-year-old female patient who is diagnosed with a non-ST segment elevation myocardial infarction. Spontaneous coronary artery dissection is suspected in the coronary angiography and then confirmed by intravascular ultrasound. Conservative management was selected, with favorable clinical outcomes.

Resumo: O diagnóstico de dissecção coronariana espontânea como causa da síndrome coronariana aguda aumentou com o surgimento das técnicas de imagem intracoronariana. Apesar disso é uma entidade subdiagnosticada. A evidência sobre o tratamento é escassa, mas o tratamento conservador mostrou resultados favoráveis em pacientes selecionados. Apresentamos o caso de um paciente de 55 anos com diagnóstico de infarto do miocárdio sem supradesnivelamento do segmento ST. Suspeita-se de dissecção coronariana espontânea na angiografia, confirmada por ultrassonografia intravascular. Se optou por tratamento conservador com boa evolução.

Disección espontánea de arterias coronarias en el puerperio. Presentación de caso / Spontaneous dissection of coronary arteries in the puerperium. Case report

RESUMEN La disección espontánea de una arteria coronaria durante el embarazo es una causa poco común de infarto agudo de miocardio, con un alto riesgo de muerte materna. El diagnóstico se realiza mediante angiografía, aunque muchos casos son diagnosticados durante la autopsia. Se presenta el caso de una mujer blanca de 38 años de edad, fumadora, multípara, que al quinto día del puerperio presentó dolor centrotorácico, opresivo e intenso, y en el electrocardiograma se evidenció un infarto agudo de miocardio anterior extenso. La coronariografía demostró disección de la arteria coronaria izquierda incluido el tronco, la descendente anterior y la circunfleja. Se realizó angioplastia primaria y se produjo trombosis hiperaguda del stent implantado. La paciente falleció al quinto día en cuadro de shock cardiogénico refractario. No hay recomendaciones de tratamiento estándar, se considera que la angioplastia primaria es el tratamiento de elección. Es esencial la integración multidisciplinaria de cardiólogo, obstetra, cardiocirujano y anestesiólogo para decidir el mejor tratamiento.

ABSTRACT The spontaneous dissection of a coronary artery during pregnancy is a rare cause of acute myocardial infarction, with a high risk of maternal death. It can be diagnosed through coronary angiography, although many cases are diagnosed during autopsy. There is presented the case of a 38-year-old white woman, smoker, multiparous, that at the fifth day postpartum presented midthoracic, oppressive and intense pain, and the electrocardiogram evidenced an extensive acute anterior myocardial infarction. The coronary angiography showed dissection of the left coronary artery including the left main, the left anterior descending and the circumflex artery. A primary angioplasty was performed and there was a hyperacute thrombosis of the implanted stent. The patient died on the fifth day in refractory cardiogenic shock. There are no standard treatment recommendations, the primary angioplasty is considered the treatment of choice. The multidisciplinary integration of cardiologist, obstetrician, cardiac surgeon and anesthesiologist is essential to decide the best treatment.

Sudden cardiac death in a young adult man due to spontaneous coronary artery dissection

@#Spontaneous coronary artery dissection is a rare event and commonly associated with pregnancy and female gender. This condition can reduce or completely obstruct the blood flow to the heart, causing a myocardial ischaemia, abnormalities in heart rhythm or sudden death. We present a case of a 28-year-old Indian male with no previous medical illness who complained sudden onset of chest pain prior to his death. Autopsy revealed a left anterior descending coronary artery dissection associated with plaque rupture. The anterior wall of left ventricle showed contraction band necrosis. There was also atheroma present in the right coronary artery which was insignificant. Histologically, dissection was associated with atherosclerosis. There was no evidence of vasculitis. The cause of death was given as coronary artery dissection due to coronary artery atherosclerosis.

Coronary angioplasty in spontaneous coronary artery dissection—Strategy and outcomes

Objective To study the clinical, angiographic and technical characteristics of patients with spontaneous coronary artery dissection (SCAD) undergoing percutaneous coronary intervention (PCI). Methods This was a retrospective single center study where patients with angiographically confirmed SCAD undergoing PCI over a period of 4 years (2013–2017) were analyzed. We also sought to identify the clinical and angiographic predictors of procedural failure during PCI. Results There were a total of 42 patients with angiographically confirmed SCAD during the study period of which 16 patients (38.1%) underwent PCI. 14 out of the 16 patients (87.5%) taken up for PCI had technical success. In all patients the lesion was initially attempted to cross with a floppy wire and if unsuccessful it was escalated to a hydrophilic wire and finally to a stiff wire The SCAD lesion was crossed with a floppy wire in 71.4% of patients, with a hydrophilic wire in 14.2% and a stiff wire in 7.1% of patients. Wire escalation was required in 5 patients (31.3%) and in 60% of cases there was a technical success after wire escalation. Presence of diabetes mellitus, hypertension, dyslipidemia, smoking, coexisting atherosclerosis, diffuse nature of the lesion, and baseline Thrombolysis in Myocardial Infarction (TIMI) ≤ 2 flow did not predict procedural failure during PCI. Conclusion PCI in SCAD is associated with a fair rate of technical success in our population. Choosing an initial floppy wire and then escalating to a hydrophilic wire followed by a stiff wire is an optimal revascularization strategy.

Surgical Treatment for a Coronary Artery Saccular Aneurysm Located in the Left Main Trunk / 日本心臓血管外科学会雑誌

A 67-year-old man was admitted to our hospital with a complaint of heart failure. He had a 12-year history of chronic renal failure and hemodialysis. Coronary angiography confirmed the presence of a saccular aneurysm originating from the calcificated left main trunk with coronary artery stenosis. The aneurysm was successfully treated by saphenous vein patch repair of the orifice and coronary revascularization of the left anterior descending and circumflex arteries. A histological examination of the aneurysm wall demonstrated coronary artery dissection. Postoperative coronary angiography 2 weeks after surgery revealed no evidence of residual aneurysm and showed patent bypass grafts.

Characteristics of acute myocardial infarction caused by spontaneous coronary artery dissection in young female patients / 中华心血管病杂志

Objective@#To investigate the characteristics of acute myocardial infarction caused by spontaneous coronary artery dissection(SCAD) in young female patients. @*Methods@#In this casecontrolstudy,127 young(≤55 years) female patients with acute myocardial infarction onset within 1 week in Nanjing first hospital, Xuzhou central hospital, affiliated hospital of Xuzhou medical university, and Lianyungang first people's hospital were enrolled between January 2013 and February 2017,and the clinical data were retrospectively analyzed. According to their clinical manifestations and coronary angiography(CAG) results,the patients were divided into coronary atherosclerosis disease(CAD) group(CAG evidenced atherosclerosis, n=83) and SCAD group(CAG detected coronary artery dissection,n=44).The SCAD patients were subdivided into definite group (the results affirmed from intravenous ultrasound or optical coherence tomography, n=21) and probable group (the CAG results highly confirmed to characteristics of SCAD,but no intravenous ultrasound or optical coherence tomography image affirmation,n=23). Then, according to the different treatment strategies, the SCAD patients were subdivided into conservative treatment group(treated with drugs,n=19) and interventional therapy group(treated with percutaneous coronary intervention,n=25). @*Results@#(1)Compared to CAD group, patients in the SCAD group had less risk factors, such as hypertension history (25.0% (11/44) vs. 45.8% (38/83) , P=0.022) and diabetes history (6.8% (3/44) vs. 21.7% (18/83) , P=0.043),and had lower levels of fasting blood glucose (5.34(4.59,5.87) mmol/L vs. 7.12(5.18,8.60)mmol/L, P=0.001),total cholesterol((3.94±1.14) mmol/L vs. (4.91±1.50) mmol/L, P=0.001),triglyceride(1.42 (0.91,1.64) mmol/L vs. 1.89 (1.23,2.45) mmol/L, P=0.005),and low density lipoprotein cholesterol ((2.24±0.91) mmol/L vs. (2.94±1.16) mmol/L, P=0.001),CAG results showed that patients in the SCAD group had more single vessel lesion (88.6% (39/44) vs. 39.8% (33/83) , P=0.001), and their target lesion stenosis was less severe ( (79.2±22.4) % vs. (91.5±12.1) %, P=0.001). (2) The clinical risk factors such as hypertension history, diabetes history, smoking history, family history of cardiology disease, fasting blood glucose,total cholesterol,triglyceride and low density lipoprotein cholesterol were similar between definite group and probable group (all P>0.05). CAG results showed that prevalence of single vessel lesion (100% (21/21) vs. 78.3% (18/23) , P=0.050) and percent of target lesion stenosis ( (76.9±20.6) % vs. (81.2±24.1) %, P=0.529) were similar between definite group and probable group.(3)There were no significant difference in single vessel(84.0% (21/25) vs. 94.7% (18/19) , P=0.370), target lesion stenosis(85.0(70.0,100.0)% vs. 75.0(50.0,90.0)%, P=0.186),and survival rates in hospital(96.0% (24/25) vs. 100% (19/19) , P=1.000) between interventional therapy group and conservative treatment group.@*Conclusions@#Prevalence of SCAD is highin young female patients with acute myocardial infarction. Acute myocardial infarction patients with less risk factors of CAD and with CAG showing smooth lesion of narrowing segment and normal finding in the other vessels, are more likely to be diagnosed with SCAD.Acute myocardial infarction patients caused by SCAD have high survival rate either receiving percutaneous coronary intervention or drug treatment.

Multivessel spontaneous coronary artery dissection presenting as acute myocardial infarction

No abstract available.

Spontaneous left anterior descending coronary artery dissection requiring coronary artery bypass surgery

Abstract Introduction: Spontaneous coronary artery dissection is a sudden separation between the layers of a coronary artery wall, non-iatrogenic or trauma related, that has been recognized as an important cause of myocardial infarction. Objective: To report an emblematic case, in terms of angiographic images, clinical presentation and predisposing factors, whose clinical management failure led to surgical intervention. Methods: A previously healthy 48-year-old male farmer was admitted to the emergency room complaining of anterior chest pain described as "tearing", which started after physical exertion. Anterior wall ST-segment depression was observed in the electrocardiogram and troponin levels were increased. The patient then underwent coronary catheterization. Angiography showed a tortuous left anterior descending coronary artery with a dissection line involving proximal and middle segments, resulting in mild to moderate luminal stenosis. At first, a conservative approach was chosen. Control cardiac catheterization, 3 months later, showed dissection progression to the distal segment. Results: The patient was referred to surgical treatment. Internal thoracic artery and a great saphenous vein graft were used to revascularize the target vessels. He had an uneventful postoperative course. Conclusion: In this report, we describe a typical clinical manifestation of an uncommon cause of acute myocardial infarction. The dissection was started by an extreme physical effort, which is a known triggering factor. Management of these cases is always challenging because there are no evidence-based therapies or guideline-based recomendations.

Spontaneous Coronary Artery Dissection in a female patient with fragile X syndrome / 고신대학교의과대학학술지

We report a case of Spontaneous coronary artery dissection associated with fragile X syndrome. The relationship between fragile X syndrome and Spontaneous coronary artery dissection is unclear. However, More research will need about the causes and treatment of Spontaneous coronary artery dissection.