Spontaneous Coronary Artery Dissection: A Difficult Journey from Emergency Coronary Artery Bypass Grafting to Left Ventricular Assist Device

Abstract

Abstract Background Excluding spontaneous coronary artery dissection (SCAD) as an etiology of acute coronary syndrome in young adults is imperative. Case Summary A previously healthy 39-year-old woman experienced sudden severe chest pain, ST-segment elevation on ECG, necessitating high-dose aspirin and urgent transfer to a revascularization center. Suffering ventricular tachycardia (VT) and ventricular fibrillation (VF), she underwent two rounds of advanced life support and venoarterial extracorporeal membrane oxygenation (VA-ECMO). Diagnosed with left main coronary artery (LMCA) SCAD, she was initially started on conversative therapy for declining left ventricular ejection fraction (LVEF). However, she continue to experience an escalating anginal symptoms, worsening biomarkers, and LMCA SCAD progression which urged the need for surgical intervention with coronary artery bypass graft surgery (CABG). Following her CABG, she experienced a worsening of her functional mitral regurgitating which she underwent transcatheter edge-to-edge repair (TEER) of her severe mitral regurgitation. Despite being listed for heart transplantation (OHTx), her low body mass index and elevated antibodies necessitated HeartMate III left ventricle assist device (LVAD) for bridge-to-transplant. Treating frequent ventricular tachycardia (VT) episodes with medications, she eventually received an LVAD as a bridge to cardiac transplantation, navigating through complications. Within one year of her receiving LVAD, she underwent a successful OHTx. Discussion The pathogenesis of SCAD involves intramural hematoma formation through intimal tears or vasa vasorum hemorrhage. Adverse outcomes in the patients described, characterized by cardiac arrest, cardiogenic shock, reduced left ventricle systolic function and occasionally serious cardiac arrhythmia – such as ventricular fibrillation – which can lead to sudden cardiac death. Although most SCAD cases heal spontaneously, revascularization can be considered in case of worsening SCAD progression. Advanced therapeutic intervention including mechanical circulatory support and OHTx should considered in refractory cases.