SPONTANEOUS CORONARY ARTERY DISSECTION: A RARE SEQUELA OF COVID-19

Abstract

TOPIC: Cardiovascular Disease TYPE: Fellow Case Reports INTRODUCTION: Spontaneous coronary artery dissection (SCAD) is a rare coronary event, mostly associated with autoimmune and inflammatory conditions. We share a case report of a patient admitted to the Creighton University Medical Center, Omaha, Nebraska with the clinical presentation and diagnostics suggestive of SCAD after coronavirus disease 2019 (COVID-19). CASE PRESENTATION: A 43-year-old caucasian woman with a history of atrial fibrillation (AF) during pregnancy, was brought to the hospital after she had a syncopal episode due to ventricular fibrillation (VF) leading to cardiac arrest requiring defibrillation on site. She had been tested positive for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) by PCR with mild symptoms, about 12 weeks prior to this episode and she recovered within a week after self-quarantine at home. In the emergency room, she had AF with a rapid ventricular response, hypothermia, bilateral decreased breath sounds, a non-tender abdomen, and equal pulses. She required endotracheal intubation for airway protection. Her initial laboratory studies revealed normal complete blood counts, CRP 71.2 mg/L, and initial Troponin I 2.55 ng/mL (with a peak of 21 ng/mL). Subsequently, she progressed to refractory cardiogenic shock necessitating four vasopressor agents. A transthoracic echocardiogram revealed a left ventricular ejection fraction of 20% with new-onset global hypokinesis and myocardial wall thickness. The coronary angiogram revealed SCAD in the left circumflex artery. An Impella device was placed for cardiovascular support initially, but she ultimately required Veno-arterial (VA) ECMO. She was also given pulse dose IV methylprednisone due to concerns for myocarditis as a late inflammatory sequela of COVID-19. She was managed conservatively without coronary intervention. The follow-up TTE one week later showed improvement in her LVEF to 60%. DISCUSSION: SCAD should be kept in the differential diagnosis in the patients who have COVID-19 infections within the past 2-12 weeks and noted to have symptoms of an acute coronary syndrome (ACS) or new-onset cardiac arrhythmias. So far there are very few reported cases of SCAD after COVID-19, all having a variable clinical course (1–3). Overall, SCAD is an underreported coronary event and has a prevalence of around 4%, mostly associated with autoimmune and inflammatory diseases. Various mechanisms of SCAD have been proposed including infection-related endothelial dysfunction and intra-plaque hemorrhage leading to an intra-adventitial hematoma, followed by longitudinal spread along the coronary artery and eventually dissection. Even though SCAD can be due to other contributory factors in critical illness, however, the association of SCAD with COVID-19 needs to be further elaborated. CONCLUSIONS: COVID-19 may lead to various cardiovascular disorders ranging from ACS to SCAD and management protocols need further research. REFERENCE #1: Kumar K, Vogt JC, Divanji PH, Cigarroa JE. Spontaneous coronary artery dissection of the left anterior descending artery in a patient with COVID-19 infection. Catheter Cardiovasc Interv [Internet] 2021;97(2). Available from: https://onlinelibrary.wiley.com/doi/10.1002/ccd.28960 REFERENCE #2: Aparisi Á, Ybarra-Falcón C, García-Granja PE, Uribarri A, Gutiérrez, and H, Amat-Santos IJ. COVID-19 and spontaneous coronary artery dissection: causality? REC Interv Cardiol (English Ed [Internet] 2021;Available from: https://www.recintervcardiol.org/en/?option=com_content&view=article&id=548&catid=41 REFERENCE #3: Shojaei F, Habibi Z, Goudarzi S, et al. COVID-19: A double threat to takotsubo cardiomyopathy and spontaneous coronary artery dissection? Med Hypotheses [Internet] 2021;146:110410. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0306987720333016 DISCLOSURES: No relevant relationships by Faran Ahmad, source=Web Response No relevant relationships by Arslan Ahmed, source=Web Response No relevant relationships by Austin Loranger, source=Web Response Speaker/Speaker's Bureau relationship with Boehringer Ingelheim Pharmaceuticals, Inc. Please note: $5001 - $20000 by Doug Moore, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Genentech Please note: $1001 - $5000 by Doug Moore, source=Web Response, value=Honoraria No relevant relationships by Sanu Rajendraprasad, source=Web Response No relevant relationships by Renuga Vivekanandan, source=Web Response