Left Main Pseudoaneurysm After Postpartum Coronary Dissection

Abstract

The patient is a 34-year-old woman, para 3, gravida 3, with dyslipidemia and former tobacco use, who 1-week postpartum experienced an acute myocardial infarction. Initial angiography revealed a left main (LM) artery dissection with probable subintimal hematoma extending into the proximal left anterior descending (LAD) and left circumflex (LCX) coronary arteries (Figure 1A). Left ventriculography revealed anterior and apical akinesis with an ejection fraction of 30%. Because definitive therapy with percutaneous revascularization carries the risk of dissection extension and occlusion and because there was minimal luminal encroachment and TIMI (thombolysis in myocardial infarction) flow grade 3, we elected for medical therapy, including aspirin, and further observation. Also controversially, we elected not to anticoagulate because of the theoretical potential to maintain false lumen patency. Figure 1. A , Initial angiography suggests left main coronary dissection (X). Narrowing of the proximal left ascending (Y) and proximal left circumflex (Z) coronary artery segments compared to the corresponding midsegments suggests intramural hematoma. B , Surveillance angiography 1 week later reveals clear extension of dissection into left circumflex artery and near obliteration of the mid-left ascending artery (arrow). Because of the high-risk nature of the problem and the unpredictable natural history, surveillance angiography 1 week after myocardial infarction was performed and revealed obvious progression of the LM dissection flap into the proximal LAD and LCX arteries, with significant luminal narrowing and TIMI 2 flow in the LAD artery (Figure 1 …