Abstract 14974: Spontaneous Coronary Dissection: A Challenging Case of Young Weightlifter

Abstract

A 26-year-old weightlifter with no significant past medical history presented with chest pain while performing his routine exercise. ECG showed anterior ST elevation myocardial infarction with subsequent angiography revealing 99% occlusion in the proximal LAD with extensive thrombus burden along with a 100% occluded distal RCA with left to right collaterals present, indicating an RCA subacute/chronic lesion (see image). An intra-aortic balloon pump was inserted, and the patient was transferred to UC Davis Medical Center. Repeat angiography revealed thrombus and dissection in the proximal LAD and RCA, stabilized with heparin drip and Gp2b3a inhibitor. Transthoracic echocardiogram showed a severely reduced ejection fraction of 15%. After heart team discussion, the patient was deemed high risk for surgery, so he underwent percutaneous coronary intervention with balloon angioplasty and deployment of drug eluting stents to the LAD and RCA with resulting TIMI-3 flow. He was initiated on guideline directed medical therapy and discharged home with LifeVest. Unfortunately, he presented with ventricular tachycardia (VT) after LifeVest shock on the following day. Repeat angiogram did not show any in-stent restenosis or thrombus. Implantable cardioverter-defibrillator (ICD) was implanted, and the patient was started on amiodarone. The patient continued to have recurrent VT. Lidocaine was added and MRI was done, which showed a large scar burden. Left ventricular assist device Impella 5.5 was placed, and the patient eventually underwent successful cardiac transplant. This case report highlights weightlifting causing spontaneous coronary dissection. It is rare but has devastating complications with limited options for acute management. Revascularization options have limited success in a patient with such an extensive scar burden and a severely reduced ejection fraction.