Coronary Artery Dissection Research Articles

Variability of time to healing of Spontaneous Coronary Artery Dissection assessed through coronary CT angiography

Abstract Background Spontaneous coronary artery dissection (SCAD) results from a spontaneous, non-traumatic, and non-iatrogenic separation of the coronary arterial wall by intramural hematoma caused by intimal tear or spontaneous hemorrhage that is unrelated to atherosclerosis. SCAD is an important cause of myocardial infarction particularly in young to middle-aged women. Natural history of this condition is poorly understood: spontaneous healing has been demonstrated through coronary angiography in the vast majority of patients at long term follow up, but the timing of healing is still not clear. Nowadays, Coronary CT angiography (CCTA) is emerging as a noninvasive option to evaluate SCAD healing at least for coronary arteries with diameter ≥2mm and could help in understanding the natural history of this condition. Methods In this single-centre, retrospective study, patients affected by SCAD between 2017 and 2022 were included. Patients with SCAD involving coronary arteries with diameter ≥2mm who did not undergo percutaneous coronary intervention (PCI) and underwent to at least one CCTA during follow up were evaluated with regard to evolution of SCAD and time to healing. Results Among 93 patients for whom diagnosis of SCAD was posed by coronary angiography, 33 conservatively managed patients (84.8% female, mean age 51.8±12.3 years) underwent to at least one CCTA during follow up. At a median time of 49 days (IQR 13 to 82 days), a complete healing of SCAD was demonstrated in 6 patients (18.2%), while most of the patients showed a stability or partial healing and 1 patient (3.0%) an extension of SCAD. During further follow up, of 10 patients who did not show a significant healing at the first CCTA, 4 patients showed a complete healing, while 6 patients showed a stability of SCAD extension or only partial healing at the longest available CCTA follow up (median follow up 191 days, IQR 96 to 249 days). As regards clinical events, no death, myocardial infarctions, or target vessel PCIs were reported during follow up. Conclusion Spontaneous healing is commonly seen in SCAD and can be demonstrated by CCTA. However, the timing of complete healing is largely variable between individuals: therefore, studies focusing factors impacting natural history of SCAD are needed.

Breaking the silence: uncovering the underdiagnosis of SCAD in young women with acute coronary syndromes

Abstract Background Spontaneous Coronary Artery Dissection(SCAD) is a recognized cause of Acute Coronary Syndrome (ACS), particularly in young women. Despite increasing awareness, underdiagnosis of SCAD remains common. Given the distinct differences in management and potential outcomes, a prompt and accurate diagnosis of SCAD is crucial for appropriate treatment and follow-up. Purpose To assess the prevalence and implications of SCAD underdiagnosis in young women with ACS and to identify potential indicators of SCAD. Methods We included consecutive women aged ≤55 years with an ACS referred for coronary angiography (CAG) to a tertiary center from 2012 to 2021. All index CAG’s and when available intracoronary imaging recordings were retrospectively reviewed to identify angiographic signs of SCAD according to the Yip-Saw criteria. Known cardiovascular risk factors, predisposing conditions for SCAD, and major adverse cardiovascular events (hospital visits, recurrent ACS, target vessel revascularization, stroke) were collected during hospitalization and follow-up. SCAD patients were compared to ACS patients without SCAD (atherosclerotic coronary artery disease, coronary spasm, no abnormalities). Subsequentially, the initially recognized SCAD patients were compared to the reclassified SCAD patients. Results 293 patients (mean age 48±5 years) were included, 217 (74%) presenting as STEMI and 64 (22%) as NSTEMI. Based on retrospective analysis of the (intra)coronary images SCAD was the underlying cause of the ACS in 17% of all patients (n=50/293) while only recognized at initial diagnosis in 26% (n=13/50) of these cases. SCAD type 2a was most frequently missed (30%). Compared to ACS patients without SCAD, SCAD patients were younger (47±6 vs. 49±5 years, p<0.05), had lower rates of smoking (28% vs. 60%, p<0.05) and less often a history of dyslipidemia (10% vs. 24%, p<0.05) and diabetes (2% vs. 16%, p<0.05). Furthermore, the coronary tortuosity score was higher (4.7±2.0 vs. 3.0 ±1.5, p<0.05). Invasively treated SCAD patients often received ≥3 coronary stents when compared to ACS patients without SCAD (28% vs. 15%, p=0.02) mostly due to hematoma extension. Follow-up showed ACS based on atherosclerosis occurred less often in SCAD patients compared to non-SCAD patients (resp. 9% vs. 14%, p<0.05), and recurrent SCAD was only recorded in reclassified SCAD patients (5% vs. 0%, p<0.05). On multi-variate analysis, the coronary tortuosity score (1.58 [1.3-1.88]) was associated with SCAD. Conclusion This study reveals that underdiagnosis of SCAD is common in young women with ACS leading to incorrect treatment with specific medication and excessive coronary stenting. Healthcare providers should be cautious for SCAD in young ACS patients with few cardiovascular risk factors and high coronary tortuosity scores. This study emphasizes the need for greater awareness and improved diagnostic methods for SCAD in young women with ACS.

Spontaneous Coronary Artery Dissection: A Case Series Reviewing Typical Presentations of an Atypical Pathology

Introduction: Spontaneous coronary artery dissection (SCAD) is a rare cause of myocardial infarction. Patients suffering SCAD are often young women without typical risk factors for atherosclerotic heart disease. Clinicians should maintain a high index of suspicion for SCAD.Case series: We report three cases of patients with SCAD from a single physician in a six-month period. Each case is unique and highlights the varied presentations and epidemiological risk factors associated with this condition.Discussion: We believe these cases are unique in that they provide insights into the variable presentations and conditions frequently associated with SCAD and will help clinicians maintain a high index of suspicion for this difficult to diagnose and rare cause of type 2 myocardial infarction. We discuss differences in interventional techniques and medical management.

Abstract 12535: Spontaneous Coronary Artery Dissection in Women: A New Role for Autoimmunity?

Introduction: Spontaneous coronary artery dissection (SCAD) is an uncommon cause of myocardial infarction (MI) in women, with a still unclear pathophysiology. Autoantibodies targeting angiotensin-II receptor type 1 (AT1R) and endothelin-1 receptor type A (ETAR) (AT1R-AAs and ETAR-AAs, respectively) lead to endothelial dysfunction and have already been associated with aortic dissection. Hypothesis: We hypothesized that titers of AT1R-AAs and ETAR-AAs are higher in patients with SCAD compared to controls. Methods: Our case-control study was conducted at Padua University Hospital between January 2022 and June 2022. Female patients diagnosed at coronary angiography with MI and SCAD were consecutively enrolled. Ten women with SCAD and 20 age-matched controls (10 women with ST-elevation MI (STEMI) and 10 healthy women) were included. Serum levels for AT1R-AAs and ETAR-AAs were determined for each participant. Absolute autoantibody titers and seropositivity prevalence were compared between SCAD patients, STEMI patients, and healthy women. Seropositivity was defined according to the threshold value suggested by the manufacturer (>10 U/mL). Results: Six out of 10 (60%) women with MI and SCAD were seropositive for AT1R-AAs and ETAR-AAs. In contrast, only one (10%) healthy woman and one (10%) STEMI patient were seropositive for AT1R-AAs (p=0.03 and p=0.03, respectively). One STEMI patient was seropositive for ETAR-AAs, while none of the healthy women was found to be seropositive (p=0.03 and p=0.01, respectively). The median autoantibody titer was significantly higher in SCAD patients than in healthy women (p=0.01 for AT1R-AAs; p=0.02 for ETAR-AAs) and STEMI patients (p<0.001 for AT1R-AAs; p=0.002 for ETAR-AAs). Conclusions: AT1R-AAs and ETAR-AAs seropositivity is significantly higher in SCAD women than in healthy women or female patients with STEMI. Our findings suggest a possible role for AT1R-AAs and ETAR-AAs in the pathophysiology of SCAD in women with MI.

Abstract 19127: The Effect of Frailty on 30 Day Rate of Readmission Among Patients With N/Stemi and Spontaneous Coronary Artery Dissection

Introduction: Spontaneous coronary artery dissection (SCAD) can present as myocardial infarction or sudden death, particularly in young patients. SCAD is primarily diagnosed on angiography thus the majority of patients present with findings of ST-elevation myocardial infarction (STEMI) or non-ST-elevation myocardial infarction (NSTEMI). Hypothesis: We sought to determine the 30-Day readmission rate (30-DRr) for STEMI/NSTEMI in frail individuals with SCAD and its impact on healthcare utilization and economic burden in the United States. Methods: Using the 2020 National Readmission Database and International Classification of Diseases, 10th revision (ICD-10) codes, a retrospective study of patient discharges with N/STEMI as a primary diagnosis and with SCAD as a secondary diagnosis. The primary outcome was 30-DRr, while secondary outcomes were readmission mortality rate, length of stay, and resource utilization defined by hospital charge (HC). Outcomes were analyzed to compare frail and non-frail individuals. Results: A total of 19,277 index hospitalizations for N/STEMI with a secondary diagnosis of SCAD were identified. The mean age on index admission was 59.53 ± 12.10 years, 57.16% (11,018) were female, and the in-hospital mortality rate was 5.84% (n = 1,125.70). There were 4,068 (21.10%) frail individuals identified. The 30-DRr was 13.30% for frail patients vs 6.51% for non-frail patients (adjusted p < 0.001). There was an 18.48% in-hospital mortality for frail individuals vs 2.46% mortality for non-frail individuals (adjusted p < 0.001). There were also significant increases in length of stay for frail patients, 9.58 days, vs 3.49 days for non-frail patients (adjusted p < 0.001), and total HC for frail patients $61,068.09 when compared to non-frail, $25,248.12 (adjusted p < 0.001). Conclusions: Frail patients with SCAD are at higher risk for readmission when compared to non-frail individuals with SCAD. The implications of this data include the possible implementation of closer follow-up with cardiology post-discharge, and need for further studies into the clinical course, interventions, and outcomes associated with SCAD.

Abstract 19053: Peripheral Eosinophil Count is Associated With Left Ventricular Systolic Dysfunction During Spontaneous Coronary Artery Dissection

Background: Spontaneous coronary artery dissection (SCAD) is an underdiagnosed condition disproportionally affecting young women, particularly during the peripartum period and/or in the presence of systemic inflammatory and autoimmune diseases. Tissue-level studies have demonstrated inflammatory infiltrates with adventitial or peri-adventitial eosinophilia at the site of SCAD lesions. Less is known regarding how systemic markers of immune activation associate with cardiac dysfunction in SCAD. Hypotheses: Higher eosinophil count and Neutrophil-to-Lymphocyte Ratio (NLR) associate with LV systolic dysfunction in SCAD patients. Methods: In individuals diagnosed with SCAD who underwent CBC with differential and echocardiography within the same presenting hospital encounter, we performed age- and sex-adjusted logistic regressions with eosinophil count (% of differential) and NLR (% of differential) as primary exposures and LVEF<55% as the dichotomous endpoint. A p<0.05 was considered statistically significant. We explored associations of neutrophil, lymphocyte, monocyte, and basophil counts with LVEF in secondary analyses. Results: In SCAD patients with complete CBC and LVEF data (N=36; mean age 49.9 years at diagnosis, 28 female), peripheral eosinophil count was associated with significantly higher odds of systolic dysfunction [OR of LVEF<55% per every 1% higher eosinophil count = 1.87; 95% CI 1.04, 3.36; p=0.04]. NLR ratio was not associated with LV systolic dysfunction (OR 1.05; 95% CI 0.94, 1.18; p=0.35) nor were other circulating leukocyte fractions. Conclusion: Peripheral eosinophil count, but not other circulating leukocyte counts, was associated with LV systolic dysfunction as measured by LVEF <55%. These findings provide complementary support to pathology-based evidence of eosinophilia observed in SCAD lesions and require confirmation in future longitudinal studies of changes in LV function following SCAD events.

Abstract 11638: Physician Attitudes Toward Beta Blocker and Antiplatelet Therapy in Spontaneous Coronary Artery Dissection Patients

Background: Spontaneous Coronary Artery Dissection (SCAD) primarily affects younger women and is a cause of acute coronary syndrome for which medical management guidelines and clinical trial data are lacking. Our study assessed physician attitudes toward beta blocker (BB) and antiplatelet therapy (APT) in SCAD. Methods: We conducted an online survey among 165 physicians who treat SCAD. Data were collected about their demographics, BB and APT prescribing practices in hypothetical SCAD patients each with one key difference from the base case, and willingness to randomize patients to BB or no BB and to dual APT [DAPT] (12 months of aspirin and P2Y12 inhibitor, then only aspirin) or single APT [SAPT] (3 months of aspirin, then no APT). Results were analyzed with descriptive statistics and chi-squared test. Results (Table): Of the respondents, 163 (99%) were cardiologists, and 64 (39%) were women. When considering BB at discharge, 88% of physicians would prescribe BB in the base case of an otherwise healthy 49-year-old woman with SCAD, with higher likelihood of prescribing BB in a patient with hypertension or ejection fraction (EF) < 50%. Most physicians (95%) were willing to randomize the base case to BB or no BB. Respondents expressed uncertainty about the benefit of BB use, particularly in patients with normal blood pressure or with EF > 50%. When considering APT at discharge, 38% of physicians would prescribe DAPT, 46% would prescribe SAPT, and 16% would prescribe no APT in the base case. Most physicians (92%) were willing to randomize the base case to the DAPT or SAPT strategies. Physicians expressed concern about inadequate and excessive APT, indicating a range of opinions. Conclusion: Most physicians would prescribe BB and APT at discharge after SCAD, with the type of APT varying widely. Nearly all were willing to randomize patients to BB or no BB and to DAPT or SAPT. Our results suggest clinical equipoise exists for BB and APT use in SCAD and point to the need for clinical trial data.

Abstract 13027: Hospital Outcomes and Predictors of Spontaneous Coronary Artery Dissection With Concurrent Ventricular Arrhythmias

Background: While spontaneous coronary artery dissection (SCAD) patients can present with ventricular arrhythmias (VAs), the in-hospital outcomes among these patients are not well-established. Objective: This study aimed to analyze the in-hospital outcomes of patients with SCAD and concurrent VAs, and to determine the predictors of VAs occurrence in this population. Methods: Using the Nationwide Readmissions Database, our study included patients aged 18 years or older who had SCAD between 2017 and 2020. We categorized the cohort into two groups depending on the presence of VAs during hospitalization. The in-hospital outcomes were assessed between two groups. Through multivariable analysis, we further analyzed the predictors of VAs occurrence among SCAD patients. Results: Our study included 160 (13.45%) SCAD patients with concurrent VAs and 1,030 (86.55%) SCAD patients without concurrent VAs between 2017 and 2020. SCAD patients with concurrent VA were associated with higher rates of early mortality (11.88% vs. 2.04%, p<0.01), prolonged index hospital stay (≥7 days) (31.25% vs. 12.82%, p<0.01), and non-home discharge (21.88% vs. 6.50%, p<0.01). The length of hospital stay was longer in the SCAD with concurrent VAs group (6.93 days vs. 3.73 days, p<0.01), and the median cumulative cost of hospitalization was also higher in this group ($31,450 vs. $14,664, p<0.01). SCAD with concurrent VAs patients also had poorer in-hospital adverse events. In multivariable analysis, the independent predictors for VAs occurrence among SCAD patients were chronic liver disease (aOR: 2.18; 95% CI: 1.15- 4.12, p=0.02) and heart failure (aOR: 3.40; 95%CI: 2.30- 5.02, p<0.01). Conclusion: Ventricular arrhythmias among SCAD patients were associated with poorer in-hospital outcomes. Heart failure and chronic liver disease were the predictors of VAs in SCAD patients. This highlights the importance of closely monitor and aggressive VAs management among these high-risk patients.

Abstract 13479: Impact of ST-Elevation Myocardial Infarction Among Hospitalized Patients With Coronary Artery Dissection: A United States Population-Based Cohort Study

Introduction: ST-Elevation myocardial infarction (STEMI) is a rare but serious complication of coronary artery dissection (CADi). There is paucity of data on the in-hospital outcomes of hospitalized patients with CADi complicated by STEMI. Methods: We queried the National Inpatient Sample to identify patients with CADi who developed STEMI during the index hospitalization using appropriate ICD-10 codes between 2018-2020. We aim to investigate the impact of STEMI among CADi patients based on in-hospital mortality, risk for cardiogenic shock and arrythmias, utilization of coronary intervention, mechanical circulatory support, and mechanical ventilation. A multivariable logistic regression analysis was used to calculate adjusted odds ratios (ORs) for the outcomes of interest. Results: A total of 20,941 hospitalized patients with CADi were identified, of which 5.42% (1135/20,941) had concomitant STEMI during the index hospitalization. The overall in-hospital mortality rate among hospitalized patients with CADi was 6.45% (1,351/20,930). Among those with concomitant STEMI, the in-hospital mortality was significantly elevated to 18.5% (210/1,135, p= 0.00) compared to those who did not have STEMI. After adjusting for possible confounders, concomitant STEMI in CADi patients was found to be an independent significant predictor of increased risk for cardiogenic shock, development of ventricular tachycardia, ventricular fibrillation, utilization of percutaneous coronary interventions, coronary artery bypass graft, mechanical ventilation, and in-hospital mortality (Table 1). Conclusions: STEMI among CADi patients was independently associated with poorer cardiovascular and in-hospital mortality outcomes. Therefore, prompt recognition and treatment of underlying STEMI in CADi patients is necessary to prevent adverse outcomes.

Abstract 18234: The Fast and the Furious, A Rare Case of RCA Dissection Following a Car Accident in a Male Patient

Introduction: Coronary artery dissection is a rare, but potentially lethal, etiology of chest pain in the emergency department. Dissection is defined as a spontaneous, traumatic, or iatrogenic disruption of the tunica intima, causing blood to accumulate in a false lumen. Coronary artery dissection reportedly has a 0.1% incidence in the general population, occurring most commonly in the LAD, and less commonly in the RCA. Acute myocardial infarction (AMI) following blunt chest trauma has an age predominance of 82% being less than 45 years of age. With a low incidence and abnormal age presentation, an electrocardiogram must be included in the work-up of blunt chest trauma to assess for coronary artery dissection. Case: A 44-year-old male with a history of polysubstance abuse, obesity, and hypertension presented with left hip pain following a motor vehicle accident. The patient had been operating a small motorcycle when he struck a stationary vehicle. He was wearing a helmet but was ejected from the motorcycle, landing on his back. The patient eventually began to experience both right-sided chest pain as well as right-sided neck pain while in the. An electrocardiogram was performed that showed inferior ST-segment elevation with reciprocal ST-segment depression in the lateral leads. Troponins were 42ng/L, 1,465ng/L and 8,170ng/L. Cardiac catheterization revealed a spiral dissection of the RCA extending from the ostium to the mid-segment with TIMI 1 flow. The patient remained on medical management of aspirin, clopidogrel, and heparin and was monitored in intensive care for 48 hours prior to home discharge. Conclusion: Blunt force cardiac injury is an uncommon cause of chest pain and myocardial infarction, and rarer still is RCA dissection. This case highlights the distinct importance of electrocardiograms as a pivotal part of the trauma and chest pain diagnostic reasoning process.

Abstract 18714: Myocardial Infarction With Non-Obstructive Coronary Artery Disease in a Young Woman - The Cardinal Role of Coronary Reactivity Testing in Unveiling the Underlying Etiology

43-year old female presented to the emergency department with substernal chest pain. She had similar symptoms years ago without obstructive CAD on coronary angiogram and was diagnosed with myocarditis. Presenting ECG revealed new anterolateral T wave inversions (Fig 1), and high-sensitivity troponins peaked at 322 ng/L consistent with NSTEMI. TTE was significant for global hypokinesis of the left ventricle with a reduced ejection fraction of 35 to 40%. Invasive coronary angiogram showed no obstructive CAD or spontaneous coronary artery dissection however there was reduced flow in the mid to distal LAD raising suspicion for endothelial and microvascular dysfunction. Contrast-enhanced cardiac MRI showed myocardial edema in the anterior and anteroseptal walls with elevated myocardial T1 and T2 values, and early enhancement post gadolinium administration showed an acute LAD territorial infarct (Fig 2). Findings were consistent with myocardial infarction with non-obstructive coronary artery disease (MINOCA). She was started on carvedilol for empiric treatment of coronary artery spasm and microvascular dysfunction, along with aspirin and atorvastatin. Losartan was added for heart failure management. Outpatient invasive coronary reactivity testing showed severe epicardial (70% vasoconstriction) and microvascular (80% decrease in coronary blood flow) endothelial dysfunction in response to acetylcholine (Fig 3 and Fig 4) as underlying etiology of recent MINOCA. CFR was normal. L-arginine (NO precursor) was added to the medical regimen. Patient has not had recurrence of chest pain or ACS at 1 year follow-up and LVEF normalized on repeat echocardiogram. This case shows the importance of cardiac MRI in confirming the diagnosis of MINOCA in patients with no obstructive CAD, and the crucial role of coronary reactivity testing in diagnosing and treating severe coronary endothelial dysfunction, which is aligned with the AHA/ACC MINOCA consensus document.

Abstract 15838: To Tear Again: Recurrent and Complicated Spontaneous Coronary Artery Dissection

Background: SCAD is as an infrequent cause of ACS with a predominance affecting a mean age of 42.6 years and 82% of patients being female. SCAD can be classified as primary or secondary, where primary dissections occur spontaneously, and secondary causes involve the aortic root and are a direct consequence of coronary interventions, surgery, or trauma. Case: 26-year-old female with no previous cardiac or significant family history presented with severe mid-sternal chest pain, radiating to both arms and back, and associated with nausea and cold sweats. Cardiovascular exam was unremarkable. Troponins were elevated at 0.18 and 0.59. Echo showed anteroseptal wall hypokinesis, consistent with Takotsubo cardiomyopathy. ECG showed anterolateral ST elevations. The patient went for cardiac catheterization and had spontaneous dissection of the left main into the LAD/diagonal with 100% occlusion of the LAD and 99% occlusion of the ramus/circumflex. Impella device was implanted due to persistent shock, V. fib., and cardiac arrest. Stents were placed in the proximal, mid, and distal LAD, ramus/circumflex, and LCA. The patient had an LVEF of 25%. Follow-up echo showed an LVEF of 30%, with subsequent Impella removal. Following week, LVEF increased to 45-50%. The patient began aspirin 81 mg, atorvastatin 10 mg, bisoprolol 5 mg, prasugrel 10 mg, and rivaroxaban 10 mg. Over the next few years, she had recurrent chest pain, syncope, palpitations, and a non-viable pregnancy at 12 weeks of gestation due to premature bleeding complications. 3 years after the initial SCAD, the patient presented with spiral dissection of the RCA, requiring three stents. LVEF was 30%. She is being managed with aspirin 81 mg, atorvastatin 20 mg, bisoprolol 10 mg, and prasugrel 10 mg. Discussion: The initial age of presentation of this patient makes this case unique. Risk of recurrent SCAD was present in 17% of patients at a median age of 2.8 years after the initial episode. Triggers for recurrent SCAD include extreme emotional/physical stress and pregnancy. Pregnancy it is not recommended in this patient population. Beta-blockade and adequate BP control are mainstay in medical management and reduce the reoccurrence of SCAD.

Abstract 16233: Paradoxical Coronary Embolus Associated With Right Atrial Thrombus in Cardiac Amyloidosis

Introduction: This case highlights amyloidosis’ risk for intracardiac thrombosis with an atypical presentation of paradoxical coronary embolism due to right atrial thrombus. Clinical Presentation: An 87-year-old male with atrial fibrillation not on anticoagulation, HFrEF, severe mitral regurgitation, CKD3B, and recent medically managed NSTEMI, presented with shortness of breath. Labs showed elevated Troponin-T HS (174 ng/L) and proBNP (11,955 pg/mL). Echocardiogram revealed EF 25-30% with new lateral and anterior wall akinesis, concerning for NSTEMI I. Coronary catheterization revealed possible thrombus in the left circumflex artery (Figure 1A), but distal perfusion was intact. CT angiogram was negative for coronary artery dissection, providing clearance to initiate treatment with Eliquis. Intriguingly, cardiac MRI suggested intracardiac thrombus within the right atrial appendage and patent foramen ovale (Figure 1B), and possible amyloidosis from delayed gadolinium uptake. Despite negative serologic amyloid workup, pyrophosphate scan confirmed transthyretin amyloidosis. The patient was diuresed for decompensated heart failure but hypotension and acute-on-chronic kidney disease limited Guidelines-Directed Medical Therapy at discharge. Discussion: This case elucidates the importance of recognizing the thromboembolic risk in cardiac amyloidosis patients. Studies indicate up to 30% of cardiac amyloidosis patients have intracardiac thrombi, particularly those with primary amyloidosis subtype. Notably, no correlation exists between the CHA2DS2-VASc score and the presence of left atrial appendage thrombus in patients with cardiac amyloidosis and atrial fibrillation. Despite the left atrial appendage being twice more susceptible to thrombus formation, the right atrial appendage requires attention. Timely screening in high-risk patients could enable early thrombus detection, potentially improving prognosis.

Abstract 12802: Impact of Atrial Fibrillation on Percutaneous Coronary Intervention With Orbital Atherectomy

Introduction: Patients with atrial fibrillation risk various complications following cardiovascular procedures. As there is a lack of data on the disparities in outcomes in atrial fibrillation patients undergoing orbital atherectomy (followed by the percutaneous intervention (PCI)), we aim to bridge this knowledge gap via our study. Methods: We queried cases of PCI between 2016-2020 via the National Inpatient Sample. Patients with a code for orbital atherectomy (followed by PCI) were retained as per past studies. We compared patient characteristics between patients with and without atrial fibrillation, and the adjusted odds ratios (aOR) of various complications were studied via logistic regression analysis. Results: Our analysis found 20710 patients (ages 18 and more) who underwent orbital atherectomy between 2016-2020 in the United States, which included 5250(25.4%) of cases with atrial fibrillation. Compared to cases without atrial fibrillation, patients with atrial fibrillation undergoing orbital atherectomy showed higher odds of various complications such as acute ischemic stroke (AIS) (aOR 1.507, p<0.01), sepsis (aOR 1.389, p<0.01), pericardial effusion (aOR 1.931, p<0.01), major bleeding (aOR 1.423, p<0.01), cardiogenic shock (aOR 1.258, p<0.01), acute kidney injury (AKI) (aOR 1.438, p<0.01), and mortality (aOR 1.298, p<0.01). While fewer cases of coronary artery dissections were noted among patients with atrial fibrillation (2.0% vs. 2.3%), the results were not statistically significant (aOR 0.862, p=0.256). Conclusions: Atrial fibrillation predisposed patients undergoing orbital atherectomy to poorer outcomes, including AKI, AIS, sepsis, pericardial effusion, major bleeding, cardiogenic shock, and death. Physicians must therefore address this issue via proper screening for cardiac arrhythmias pre- and post-procedure and maintain a close follow-up in at-risk individuals.

Abstract 15381: Clinical Outcomes of Post-Drug-Coated Balloon Angioplasty Dissection in Large De-Novo Coronary Artery Disease

Introduction: Drug-coated balloon (DCB) may be an alternative to stents in the treatment of large native coronary artery disease. However, the complications of acute elastic recoil and coronary dissections confine the practical application of DCB. Little is known about the clinical outcomes of different types of dissection after DCB angioplasty with or without stenting. Aims: This study sought to investigate the clinical outcomes of post-DCB dissection in large de novo coronary artery disease. Methods: This was a retrospective observational study. A consecutive series of patients with large native coronary artery disease (reference diameter ≥ 3.0 mm) who occurred coronary dissections after the treatment of DCB angioplasty were included. These patients were divided into stented groups and non-stented groups depending on whether bail-out stents were employed. Post-angioplasty coronary artery dissections were classified into type A-F. The cumulative incidence of major adverse cardiac events (MACE) was compared between the two groups. Results: Between March 2017 and October 2022, 676 patients with large de novo coronary artery disease developed post-DCB angioplasty dissection, 554 of which treated with DCB only, 122 of which underwent bail-out stent implantation. These dissections were type A (60.5%), B (30.9%), C (6.5%), D (1.9%) and F (0.1%), respectively. During a mean follow-up of 1 year, MACE occurred in 60 patients (9 in the stented group and 51 in the non-stented group; 7.4% vs. 9.2%; p=0.522). For type B dissection, the rate of MACE was similar in the stented group than that in the non-stented group (11.1% vs. 8.2%; p=0.502). For type C dissection, the rate of MACE was numerically higher in the non-stented group than that in the stented group (9.5% vs. 0%; p=0.222). Conclusions: For post-DCB angioplasty dissection in large de-novo coronary artery disease, type B dissection requires no bail-out stent implantation and type C dissection deserves further investigation.

Non-atherosclerotic acute cardiac syndromes: spontaneous coronary artery dissection and Takotsubo syndrome. Comparison of long-term clinical outcomes.

Spontaneous coronary artery dissection (SCAD) and Takotsubo syndrome (TTS) constitute two common causes of nonatherosclerotic acute cardiac syndrome particularly frequent in women. Currently, there is no information comparing long-term clinical outcomes in unselected patients with these conditions. We compared the baseline characteristics, in-hospital outcomes, and the 12-month and long-term clinical outcomes of two large prospective registries on SCAD and TTS. A total of 289 SCAD and 150 TTS patients were included; 89% were women. TTS patients were older with a higher prevalence of cardiovascular risk factors. Precipitating triggers were more frequent in TTS patients, while emotional triggers and depressive disorders were more common in the SCAD group. Left ventricular ejection fraction was lower in TTS patients, but SCAD patients showed higher cardiac biomarkers. In-hospital events (43.3% vs. 5.2%, P<0.01) occurred more frequently in TTS patients. TTS patients also presented more frequent major adverse events at 12-month (14.7% vs. 7.1%, HR 5.3, 95% CI: 2.4-11.7, P<0.01) and long-term (median 36 vs. 31 months, P=0.41) follow-up (25.8% vs. 9.6%, HR 4.5, 95% CI: 2.5-8.2, P<0.01). Atrial fibrillation was also more frequent in TTS patients. Moreover, TTS patients presented a higher 12-month and long-term mortality (5.6% vs. 0.7%, P=0.01; and 12.6% vs. 0.7%, P<0.01) mainly driven by noncardiovascular deaths. Compared to SCAD, TTS patients are older and present more cardiovascular risk factors but less frequent depressive disorder or emotional triggers. TTS patients have a worse in-hospital, mid-term, and long-term prognosis with higher noncardiac mortality than SCAD patients.

The need for improved spontaneous coronary artery dissection care

In this article, Natalie Elliot and colleagues discuss the need for improved care for patients who have experienced spontaneous coronary artery dissection.

Never say never: successful extracorporeal cardiopulmonary resuscitation (ECPR) following a prolonged out-of-hospital cardiac arrest due to spontaneous coronary artery dissection

Introduction: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) may be a life-saving rescue therapy for patients with severe cardiac disease of any origin and circulatory failure. Data in the literature have demonstrated that the use of advanced mechanical circulation has resulted in improvements in both survival and quality of life; despite this, cardiogenic shock and refractory cardiac arrest remain conditions with high mortality. Opportune identification of patients who can benefit from it may improve outcomes. However, the shortage of guidelines on indications often results in a high mortality rate and poor outcome. Due to ethical issues, randomised controlled studies with VA-ECMO have not been conducted so no recommended evidence-based guidelines exist for VA-ECMO patient-selection criteria. Therefore, the indications depend only on expert opinion after reviewing the literature. Case description: We report the case of a young female patient who presented with an out-of-hospital cardiac arrest (OHCA) due to spontaneous coronary dissection. She was treated with extracorporeal cardiopulmonary resuscitation (ECPR) with excellent results in terms of short and long-term survival, and neurological outcome. This was despite the presence of several clinical and laboratory negative prognostic factors on the basis of the current literature, and the lack of general consensus among the relevant medical personnel. Conclusion: We were able to explain the favourable outcome only on the basis of clinical data. We can conclude that the availability of advanced resources in the area (timeliness of the rescues, quality of the resuscitation, an advanced haemodynamic management centre nearby) has contributed to determining the complete clinical and neurological recovery of the patient.

Spontaneous Coronary Artery Dissection: A Case Series Reviewing Typical Presentations of an Atypical Pathology.

Spontaneous coronary artery dissection (SCAD) is a rare cause of myocardial infarction. Patients suffering SCAD are often young women without typical risk factors for atherosclerotic heart disease. Clinicians should maintain a high index of suspicion for SCAD. We report three cases of patients with SCAD from a single physician in a six-month period. Each case is unique and highlights the varied presentations and epidemiological risk factors associated with this condition. We believe these cases are unique in that they provide insights into the variable presentations and conditions frequently associated with SCAD and will help clinicians maintain a high index of suspicion for this difficult to diagnose and rare cause of type 2 myocardial infarction. We discuss differences in interventional techniques and medical management.

Left Main Spontaneous Coronary Artery Dissection in a Patient With Osteogenesis Imperfecta: Use of Multimodal Imaging

Left Main Spontaneous Coronary Artery Dissection in a Patient With Osteogenesis Imperfecta: Use of Multimodal Imaging