P134 RECURRENT SCAD IN A PATIENT WITH BICUSPID AORTIC VALVE AND ANOMALOUS CORONARY ORIGIN

Abstract

Abstract Spontaneous coronary artery dissection (SCAD) is recently emerging as an increasingly frequent cause of myocardial infarction and among the main triggering factors we found hypertension, pregnancy, fibromuscular dysplasia and connective tissue diseases (e.g. Marfan syndrome). Recent studies also suggest that even bicuspid aortic valve may be a predisposing condition for the development of spontaneous coronary artery dissection. We report the case of a 45–year–old Caucasian man with no cardiovascular risk factors; his clinical history begins in August 2019, when he was hospitalized for acute coronary syndrome (NSTEMI). Echocardiography showed preserved left ventricular ejection fraction, bicuspid aortic valve (fusion of right and left cusps) with mild to moderate regurgitation without stenosis and mild dilatation of the aortic bulb (38 mm). The coronary angiography showed no significant stenoses and an anomalous origin of the right coronary artery from the common trunk. The patient was discharged two days later with a diagnosis of MINOCA and an indication to perform a coronary CT scan, which confirmed the anomalous origin of the right coronary artery with a retro–aortic course, and a cardiac MRI, which showed myocardial edema of the infero–lateral wall, mainly with sub–endocardial distribution and LGE in the same sites, compatible with ischemic damage. In September 2022 there was a new hospitalization for inferior–posterior–lateral STEMI with coronarographic finding of a large marginal branch collateral stenosis, with recovery of distal caliber. The angiographic pattern was consistent with type II SCAD (no intracoronary imaging has been performed because of vascular tortuosity and lesion distality). A retrospective comparative analysis of the 2019 angiography allowed to find a distal occlusion of the same branch, now healed, also compatible with SCAD. The patient was discharged on single antiplatelet therapy after one week of DAPT with acetylsalicylic acid and clopidogrel and indication to perform a genetic test for connective tissue diseases. The case described prompts the cardiologists to suspect an uncommon etiology (connective tissue disease, bicuspid aortic valve) in case of SCAD detection, especially if associated with anomalous origin of the coronary arteries.