Multivessel Spontaneous Coronary Artery Dissection Research Articles

Multivessel Spontaneous Coronary Artery Dissection in the Setting of Anomalous Left Coronary Arteries.

Spontaneous coronary artery dissection (SCAD) and coronary artery anomaly can arise where all three arteries originate from the right coronary cusp;There are possible associations between SCAD and coronary artery anomalies;Treatment and management of multivessel SCAD with a coronary artery anomaly where all three arteries arise from the right sinus of Valsalva.

Multivessel spontaneous coronary artery dissection: Clinical features, angiographic findings, management, and outcomes

BackgroundSpontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome. Multivessel (MV) SCAD is a challenging clinical presentation that might be associated to a worse prognosis compared with patients with single-vessel (SV) involvement. MethodsThe Spanish multicentre nationwide prospective SCAD registry included 389 consecutive patients. Patients were classified, according to the number of affected vessels, in SV or MV SCAD. Major adverse events (MAE) were analyzed during hospital stay and major cardiac or cerebrovascular adverse events (MACCE) at long-term clinical follow-up. ResultsA total of 41 patients (10.5%) presented MV SCAD. These patients had more frequently a previous history of hypothyroidism (22% vs 11%, p = 0.04) and anxiety disorder (32% vs 16%, p = 0.01). MV SCAD patients presented more often as non-ST segment elevation myocardial infarction (73% vs 52%, p = 0.01) and showed less frequently type 1 angiographic lesions (12% vs 21%, p = 0.04). An impaired initial Thrombolysis In Myocardial Infarction (TIMI) flow 0–1 was less frequent (14% vs 29%, p < 0.01) in MV SCAD. In both groups, most patients were treated conservatively (71% vs 79%, p = NS). No differences were found regarding in-hospital MAE or MACCE at late follow-up (median 29 ± 11 months). However, the rate of stroke was higher in MV SCAD patients, both in-hospital (2.4% vs 0%, p < 0.01) and at follow-up (5.1% vs 0.6%, p = 0.01). ConclusionsPatients with MV SCAD have some distinctive clinical and angiographic features. Although composite clinical outcomes, in-hospital and at long-term follow-up, were similar to those seen in patients with SV SCAD, stroke rate was significantly higher in patients with MV SCAD.

Abstract 14370: Significant Heterogeneity in Antiplatelet Regimen for Spontaneous Coronary Artery Dissection: A Report of the ISCAD Registry

Introduction: Dual antiplatelet therapy (DAPT) is standard for patients (pts.) with acute coronary syndrome due to atherosclerosis. Evidence to support DAPT vs single antiplatelet therapy (SAPT) for spontaneous coronary artery dissection (SCAD) is limited. Hypothesis: Prescription of DAPT vs SAPT varies among specialized centers for SCAD. Methods: Analysis of 505 pts. with complete patient questionnaire, case report form, and angiography review enrolled in the iSCAD Registry from 9 sites with &gt; 20 pts. enrolled. Data are presented for 442 pts. with complete medication data who received DAPT or SAPT during index hospitalization (HOSP) and continued at discharge (DC). Results: Patient age 49.6 + 10.2 years, 83% were female. Presentation of SCAD: NSTEMI (55.9%), STEMI (26.9%), unstable angina (13.8%), cardiac arrest (4.3%), cardiogenic shock (0.2%). Most common SCAD location was the LAD (60.9%); 20.8% had multivessel SCAD. Management was: medical therapy (75.2%), PCI (22.5%), CABG (1.4%), or PCI + CABG (0.92%). During HOSP 70.1% (317/452) were treated with DAPT vs 29.9% SAPT (135/452). At DC, 74.7% were prescribed DAPT (339/442) vs 25.3% SAPT (112/452). In multivariable analyses, only PCI as SCAD treatment was associated with DAPT during HOSP (OR 3.57, 95% CI 1.90-6.70) or DC (OR 4.9, 95% CI 2.28-10.53). There was significant heterogeneity of antiplatelet regimen across sites ranging from 34.0%-87% DAPT during HOSP (p&lt;0.0001) and 53.8%-83.6% DAPT at DC (p=0.0011) (Figure). There was a trend of recurrent MI among pts. treated with DAPT vs SAPT during HOSP that did not achieve statistical significance (7.1% vs 3.0%, P=0.09). Conclusion: In the iSCAD Registry, most pts. with SCAD were treated with DAPT during index HOSP and DC with significant heterogeneity across sites. PCI during index HOSP was associated with DAPT (vs SAPT) prescription. Further study of outcomes, including recurrent MI, with DAPT (vs SAPT) during hospitalization and subsequent follow-up is needed.

Multivessel spontaneous coronary artery dissection as a cause of acute coronary syndrome: An oft-forgotten differential diagnosis.

Multivessel spontaneous coronary artery dissection as a cause of acute coronary syndrome: An oft-forgotten differential diagnosis.

Multivessel spontaneous coronary artery dissection: clinical features, angiographic findings, management, and outcomes

Abstract Background Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome. The rate of SCAD patients with multivessel (MV) involvement varies between series (6–13%)1,2. MV SCAD might be potentially associated to a worse prognosis due to a higher ischemic burden compared with patients with single-vessel (SV) involvement. However, comparative data between patients with MV versus SV SCAD is lacking. Methods The Spanish multicentre nationwide SCAD registry prospectively included 389 consecutive patients from 34 university hospitals. Patients were classified according to the number of affected vessels in two groups: SV or MV SCAD. In-hospital major adverse event (MAE) was defined as a composite of death, myocardial reinfarction, unplanned revascularization, cardiogenic shock, ventricular arrhythmia or stroke. A major cardiac or cerebrovascular adverse event (MACCE) was defined as a composite of death, myocardial reinfarction, unplanned revascularization, SCAD recurrence or stroke. Results A total of 41 patients (10.5%) presented MV SCAD (Table 1). There were no significant differences between groups regarding age, sex and distribution of most cardiovascular risk factors, with a non-significant trend towards more hypertension in the MV group (49% vs 34%, p=0.06). MV SCAD patients had more often previous history of hypothyroidism (22% vs 11%, p=0.04) and anxiety disorder (32% vs 16%, p=0.01), with a trend towards more fibromuscular dysplasia (50% vs 29%, p=0.12) among those patients screened. MV SCAD patients presented more often with NSTEMI (73% vs 52%, p=0.01). Regarding angiographic findings, MV SCAD patients presented more frequently focal type 3 lesions (19% vs 6%, p&amp;lt;0.01) and fewer type 1 double-lumen lesions (12% vs 21%, p=0.04). The rate of lesions with an impaired initial Thrombolysis In Myocardial Infarction (TIMI) flow 0–1 was lower (14% vs 29%, p&amp;lt;0.01) in MV SCAD. In both groups, most patients were treated conservatively (71% vs 79%, p=NS). We found no significant differences between groups in MAE during admission. At long-term follow-up (median 29 months), there were no significant differences in MACCE between groups (18% vs 12%, p=0.28). However, the rate of stroke was higher in patients with MV SCAD, both in-hospital (2.4% vs 0%, p&amp;lt;0.01) and at follow-up (5.1% vs 0.6%, p=0.01). This finding could be explained by the basal differences found in hypertension and fibromuscular dysplasia between MV and SV SCAD patients. Conclusions Patients with MV SCAD have some distinctive clinical and angiographic features. We found no significant differences in our primary composite outcomes, both in-hospital and at long-term follow-up, between patients with SV and MV SCAD. Rate of stroke was significantly higher in patients with MV SCAD. Funding Acknowledgement Type of funding sources: None.

Causa rara de parada cardíaca: um caso de extensa dissecção espontânea da artéria coronária esquerda

A 28-year-old male with a previous history of drug abuse was sent to an emergent coronary angiography, after a cardiac arrest, with a post-resuscitation eletrocardiogram showing ST-segment elevation from V1-V4. Angiography showed multivessel and multisegment spontaneous coronary artery dissection. Due to clinical instability, patient underwent left anterior descending artery percutaneous coronary intervention. Prevalence of spontaneous coronary artery dissection as the cause of acute coronary syndrome is anecdotal in men. Yet, in the right scenarios as in this case, it must be ruled out. Cardiorespiratory arrest is an uncommon presentation of spontaneous coronary artery dissection and percutaneous coronary intervention in spontaneous coronary artery dissection is still a matter of debate.

580 Percutaneous coronary intervention or medical therapy as initial management strategy of patients with spontaneous coronary artery dissections: insight from the multicentre, international dissezioni spontanee coronariche (disco) registry

Abstract Aims Whether patients with spontaneous coronary artery dissection (SCAD) should undergo an initial conservative management or immediate revascularization through percutaneous coronary intervention (PCI) remains debated. To investigate the frequency and predictors of choosing a strategy of immediate PCI for SCAD, and to compare the clinical outcomes of immediate PCI patients with those undergoing an initial strategy of medical management. Methods and results 369 patients enrolled in the multicentre international DIssezioni Spontanee COronariche (DISCO) registry between January 2009 and December 2020 were included. The primary endpoint was major adverse cardiovascular events (MACE), a composite of cardiac death, non-fatal myocardial infarction (MI) and any PCI. 240 (65%) patients underwent initial medical management, whereas 129 (35%) had immediate PCI. PCI patients presented more frequently with ST segment-elevation myocardial infarction (STEMI) (68.2% vs. 35%, P &amp;lt; 0.001) and had higher frequency of proximal coronary segment SCAD (31.8% vs. 6.7%, P &amp;lt; 0.001), Thrombolysis in Myocardial infarction (TIMI) flow grade 0–1 (54.3% vs. 20.4%, P &amp;lt; 0.001) and multivessel SCAD (18.6% vs. 9.2%, P = 0.015), as well as a more severe diameter stenosis [99% (100–90) vs. 90% (99–75), P &amp;lt; 0.001]. At multivariate logistic regression, STEMI at presentation (vs. NSTE-ACS, OR: 3.30 95% CI: 1.56–7.12, P = 0.002), proximal coronary segment involvement (OR: 5.43, 95% CI: 1.98–16.45, P = 0.002), TIMI flow grade 0–1 and 2 (respectively, vs. grade 3: OR: 3.22 95% CI: 1.08–9.96, P = 0.038; and OR: 3.98; 95% CI: 1.38–11.80, P = 0.009) and diameter stenosis (per 5% increase, OR: 1.13; 95% CI: 1.01–1.28, P = 0.037) were predictors of immediate PCI, whereas the angiographic subtype 2B predicted a conservative approach (OR: 0.25; 95% CI: 0.07–0.83, P = 0.026). The frequency of in-hospital major adverse cardiac events did not differ between medically and PCI-treated patients. At 2-year follow-up, there were no differences with respect to the composite of MACE (11.7% vs. 13.9%, P = 0.47) and the individual components of cardiovascular death (0.4% vs. 0.7%, P = 0.65), non-fatal MI (8.3% vs. 9.3%, P = 0.92), and any PCI (8.7% vs. 12.4%, P = 0.23). Conclusions The choice between an immediate medical or PCI management of SCAD is mostly driven by clinical presentation and procedural aspects. In the DISCO cohort, the primary treatment approach was not associated with the risk of short-to-midterm adverse events.

Multi-vessel coronary artery dissection in a patient with congenital aortopathy

Spontaneous coronary artery dissection (SCAD) is a well-documented cause of acute coronary syndrome and could have life-threatening consequences. We report the case of young female with a prior history of cardiac surgery due to congenital aortic stenosis presenting with multi-vessel SCAD. She was successfully managed with medical treatment.

Postpartum multi-vessel spontaneous coronary artery dissection in the setting of cocaine and amphetamine use: a case report

Background Spontaneous coronary artery dissection (SCAD) is a recognized cause of acute coronary syndrome (ACS). Pregnancy, the postpartum period, and illicit drug use have all been reported as potential triggers.Case summary We describe the case of a 41-year-old patient who presented to the emergency department with chest pain in the setting of recent cocaine and amphetamine use. The patient was 4 months postpartum following an uncomplicated pregnancy. Past medical history was non-contributory, with no known risk factors for ischaemic heart disease. Electrocardiogram was normal but high-sensitivity troponin T was significantly elevated. Coronary angiography revealed multi-vessel SCAD. This was managed conservatively as the patient remained clinically stable and pain free without high-risk anatomy (left main stem or proximal two-vessel coronary artery dissection).Discussion Spontaneous coronary artery dissection must be considered in a postpartum patient presenting with ACS, particularly in the context of environmental stressors such as illicit drug use. Coronary angiography is key to determine diagnosis and guide management. Conservative therapy is favoured, except for patients with ongoing ischaemia, haemodynamic instability, and left main stem involvement. In this case, we suspect SCAD occurred due to the haemodynamic effects of cocaine and amphetamines in the context of structural arterial changes of the postpartum state.

Abstract 16692: Spontaneous Coronary Artery Dissection Associated With Pregnancy

Introduction: Spontaneous coronary artery dissection (SCAD) is a rare but life threatening cause of acute coronary syndrome and a common etiology of pregnancy-associated myocardial infarction (PAMI). Hypothesis: We aimed to examine the clinical presentation, treatment, and outcomes of the largest pregnancy associated-SCAD (P-SCAD) patient cohort to date. Methods: A total of 128 women enrolled in the Mayo Clinic SCAD Registry between 2010-2020 who were pregnant or up to 1 year postpartum at time of P-SCAD were identified. We subdivided P-SCAD in an “early” group with &lt;12 weeks of delivery and a “late” group presenting between &gt;12 weeks -12 months following delivery. Results: Among the 128 women with P-SCAD, 7(5%) occurred during pregnancy (2/7 first trimester, 5/7 third trimester). Of the 121 women with postpartum P-SCAD, 88/121(72%) occurred &lt;12 weeks of delivery and 33/121(27%) at 12 weeks to 1 year postpartum. The mean age of P-SCAD was 35.3 +/- 4 years (26-48). The most common symptom on presentation was chest pain 118/128(92%); 62/128(48%) presented with ST elevation MI and 58/128(45%) presented with non-ST elevation MI. Multivessel involvement occurred in 40/128(31%), left anterior descending artery (LAD) in 88/128(69%), and left main (LM) in 28/128(22%) of all P-SCAD. Percutaneous coronary intervention (PCI) was performed in 52/128(41%) with a success rate of 81%. Coronary artery bypass grafting was performed in 24/128(19%) of which 6/24 patients had an unsuccessful PCI, 14/24 had proximal or multivessel SCAD, and 4/24 had persistent or extension of initial SCAD. Of those treated conservatively 52/128(40%), 11/52(21%) had LM and LAD. Among all the P-SCAD patients, 84/128 (66%) were screened for an underlying arteriopathy, of whom 44 (52 %) were diagnosed with fibromuscular dysplasia. At a median follow up of 3 years (IQR 1 to 6), 12/128 (9%) of all P-SCAD survivors had a recurrent SCAD event and 7/12 (58%) were within 1 year postpartum. There were no deaths. Conclusions: P-SCAD most commonly presents with ST-elevation MI and multivessel involvement within the initial 12 weeks postpartum. Clinicians need to be familiar with this etiology of PAMI to avoid delay in diagnosis and appropriate management.

Coronary angiographic manifestations of fibromuscular dysplasia and clinical outcomes in patients with spontaneous coronary artery dissection

Abstract Background Fibromuscular dysplasia (FMD) is a common predisposing condition for spontaneous coronary artery dissection (SCAD), which is an important cause of myocardial infarction (MI) in young to middle-aged women. However, its impact on clinical presentation, coronary anatomies, and outcomes have not been reported. Purpose To evaluate coronary angiographic characteristics and clinical outcomes in SCAD patients with or without underlying extracoronary FMD. Methods We retrospectively analyzed patients enrolled in our Vancouver SCAD registries who were screened for extracoronary FMD. Extracoronary FMD was defined as the presence of multifocal FMD on catheter or noninvasive angiography (computed tomographic or magnetic resonance imaging) in ≥1 extracoronary vascular beds. We reviewed coronary angiograms for manifestations of coronary FMD that were previously described (i.e. irregular stenosis, smooth stenosis, dilatation/ectasia, and tortuosity). Severe tortuosity was defined as ≥2 consecutive bends ≥180° at any cardiac cycle or 360° loop in ≥1 epicardial artery that was ≥2 mm in diameter. Clinical outcomes of major adverse cardiovascular event (MACE), a composite of all-cause death, MI, and stroke, were evaluated. Results We included 346 SCAD patients, 250 (72.3%) had extracoronary FMD. Patients with FMD were older (54.6±9.5 vs. 51.7±9.8 years) and more likely to have prior history of MI (7.2% vs. 1.0%, p=0.047) and stroke (4.4% vs. 0%, p=0.081) compared with non-FMD patients. The proportion of multivessel SCAD and TIMI flow was not different between groups, but type 3 SCAD was more commonly observed in FMD group (11.6% vs. 3.1%, p=0.026). On coronary angiography, severe tortuosity was more prevalent in patients with extracoronary FMD (58.4% vs. 36.5%, p&amp;lt;0.001), whereas rates of irregular stenosis, smooth stenosis, and dilatation/ectasia were not significantly different (Figure). Percutaneous coronary intervention was performed in 13.2% of FMD and 15.6% of non-FMD group, with similar success rates (75.8% vs. 69.2%, p=0.65). In-hospital and long-term MACE rate at median follow-up of 1032 (IQR 453–1096) days were not different between FMD and non-FMD groups (in-hospital: 5.6% vs. 8.3%, p=0.492; long-term: 19.6% vs. 15.6%, p=0.185). Conclusion In SCAD patients, severe coronary tortuosity was more prevalent in patients with FMD than those without. Despite the complex coronary anatomy, FMD was not associated with worse outcomes. Differences in coronary manifestations Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Canadian Institutes of Health Research

Multivessel spontaneous coronary artery dissection with simultaneously three different angiographic patterns

Spontaneous coronary artery dissection (SCAD) is a non-traumatic non-iatrogenic coronary dissection. It's a frequent cause of acute coronary syndrome (ACS) in women without or with few traditional cardiovascular risk factors. We report an unusual case of multivessel SCAD in a middle-aged woman with successful medical management.

Chronic infarct size after spontaneous coronary artery dissection: implications for pathophysiology and clinical management.

AimsTo report the extent and distribution of myocardial injury and its impact on left ventricular systolic function with cardiac magnetic resonance imaging (CMR) following spontaneous coronary artery dissection (SCAD) and to investigate predictors of myocardial injury.Methods and resultsOne hundred and fifty-eight angiographically confirmed SCAD-survivors (98% female) were phenotyped by CMR and compared in a case–control study with 59 (97% female) healthy controls (44.5 ± 8.4 vs. 45.0 ± 9.1 years). Spontaneous coronary artery dissection presentation was with non-ST-elevation myocardial infarction in 95 (60.3%), ST-elevation myocardial infarction (STEMI) in 52 (32.7%), and cardiac arrest in 11 (6.9%). Left ventricular function in SCAD-survivors was generally well preserved with small reductions in ejection fraction (57 ± 7.2% vs. 60 ± 4.9%, P < 0.01) and increases in left ventricular dimensions (end-diastolic volume: 85 ± 14 mL/m2 vs. 80 ± 11 mL/m2, P < 0.05; end-systolic volume: 37 ± 11 mL/m2 vs. 32 ± 7 mL/m2, P <0.01) compared to healthy controls. Infarcts were small with few large infarcts (median 4.06%; range 0–30.9%) and 39% having no detectable late gadolinium enhancement (LGE). Female SCAD patients presenting with STEMI had similar sized infarcts to female Type-1 STEMI patients age <75 years. Multivariate modelling demonstrated STEMI at presentation, initial TIMI 0/1 flow, multivessel SCAD, and a Beighton score >4 were associated with larger infarcts [>10% left ventricular (LV) mass].ConclusionThe majority of patients presenting with SCAD have no or small infarctions and preserved ejection fraction. Patients presenting with STEMI, TIMI 0/1 flow, multivessel SCAD and those with features of connective tissue disorders are more likely to have larger infarcts.

Risk Factors, Imaging Findings, and Sex Differences in Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is increasingly being recognized. However, data supporting diagnosis and management are scarce. We analyze a contemporary and comprehensive SCAD registry to advance the understanding of SCAD risk factors, angiographic appearance, and gender differences. This is a retrospective analysis of a prospectively populated database of SCAD patients seen at the Massachusetts General Hospital (MGH) between June 2013 and October 2017. Core laboratory analysis of both coronary angiograms and computerized tomographic (CT) angiography of the extracoronary vessels was performed. Of the 113 patients, 87% were female and mean age was 47 ± 10 years. Traditional cardiovascular risk factors including hypertension, hyperlipidemia, and smoking were present in 27%, 14%, and 22% of patients. Among females, 14%, 8%, and 9% had a history of gestational hypertension, pre-eclampsia, and gestational diabetes, respectively. Fifteen percent had used fertility treatment and 47% of postmenopausal women had used hormone replacement therapy. Angiography showed multivessel SCAD in 42%, severe coronary artery tortuosity in 59%, and extracoronary vascular abnormalities in 100% of patients with complete CT angiographic imaging. Gender differences revealed a self-reported depression and anxiety prevalence of 20% and 32%, respectively, in women compared with 0% in men. Type 1 SCAD was more commonly diagnosed in men than women (71% vs 29%, p <0.01). In conclusion, we highlight under-recognized features of SCAD including (1) relation with pregnancy complications and exposure to hormonal therapy; (2) diffuse, multivessel process in tortuous coronaries on a background of extracoronary arterial abnormalities; and (3) gender differences highlighting the role of mental health as well as potential underdiagnoses in men.

Coronary endothelial function and spontaneous coronary artery dissection.

To investigate the role of endothelial function in patients with previous spontaneous coronary artery dissection. Mechanisms underlying spontaneous coronary artery dissection, including a possible contribution from endothelial dysfunction, remain poorly understood. This was a single center, retrospective study of patients with a prior spontaneous coronary artery dissection episode who underwent invasive endothelial function testing in the cardiac catheterization laboratory for evaluation of recurrent chest pain. Coronary epicardial and microvascular responses to acetylcholine, adenosine, and nitroglycerine were assessed. Findings were compared to a reference group of normal controls (n=232). A total of 10 patients with prior angiographically confirmed spontaneous coronary artery dissection were referred for coronary endothelial function testing. The median coronary flow reserve was 2.8 (interquartile range (IQR) 2.3, 3.6). The median change in coronary diameter with acetylcholine was -0.9% (IQR -23.9, 4.2). The median increase in peak coronary blood flow following acetylcholine administration was 91.4% (IQR 9.1, 105.7), which was similar to the response observed in a reference group of patients (median age 51 years, 96% women) from our laboratory with normal microvascular responses to acetylcholine: 107.4% (IQR 75.5, 165.7; P=0.20). Four patients (40%) had an abnormal microvascular response to acetylcholine, with less than a 50% increase in coronary blood flow, and all but one patient had left anterior descending artery or multivessel spontaneous coronary artery dissection. Coronary epicardial and microvascular vasomotor dysfunction is not a predominant feature of spontaneous coronary artery dissection. Endothelial dysfunction is not implicated as the principal underlying mechanism.

A Rare Case of Very Late Recurrent Multivessel Spontaneous Coronary Artery Dissection in a Postmenopausal Woman

A Rare Case of Very Late Recurrent Multivessel Spontaneous Coronary Artery Dissection in a Postmenopausal Woman

253 - Multivessel Spontaneous Coronary Artery Dissection: An Incidental Finding in the Least Expected Patient

253 - Multivessel Spontaneous Coronary Artery Dissection: An Incidental Finding in the Least Expected Patient

Pregnancy and the Risk of Spontaneous Coronary Artery Dissection: An Analysis of 120 Contemporary Cases.

Because of the rarity of this condition, information on pregnancy-associated spontaneous coronary artery dissection is limited. We reviewed a large number of contemporary pregnancy-associated spontaneous coronary artery dissection cases in an attempt to define the clinical characteristics and provide management recommendations. A literature search for cases of pregnancy-associated spontaneous coronary artery dissection reported between 2000 and 2015 included 120 cases; 75% presented with ST-segment-elevation myocardial infarction, and 80% had anterior myocardial infarction. Left anterior descending coronary artery was involved in 72% of cases, left main segment in 36%, and 40% had multivessel spontaneous coronary artery dissection. Ejection fraction was reduced to <40% in 44% of cases. Percutaneous coronary intervention was successful in only 50% of cases. Coronary artery bypass surgery was performed in 44 cases because of complex anatomy, hemodynamic instability, or failed percutaneous coronary intervention. Maternal complications included cardiogenic shock (24%), mechanical support (28%), urgent percutaneous coronary intervention (28%), urgent coronary artery bypass surgery (27.5%), maternal mortality (4%), and fetal mortality (2.5%). During follow-up for 305±111 days, there was a high incidence of symptoms because of persistent or new spontaneous coronary artery dissections, and 5 women needed heart transplantation or ventricular assist device implantation. Pregnancy-associated spontaneous coronary artery dissection is commonly associated with left anterior descending, left main, and multivessel involvement, which leads to a high incidence of reduced ejection fraction, and life-threatening maternal and fetal complications. Percutaneous coronary intervention is associated with low success rate and high likelihood of complications, and coronary artery bypass surgery is often required. Recurrent ischemic events because of persistent or new spontaneous coronary artery dissection are common during long-term follow-up.

Postpartum Multivessel Spontaneous Coronary Artery Dissection

A 40-year-old postpartum woman with no relevant clinical history was admitted for myocardial infarction without ST segment elevation 12 days after a natural delivery. Emergency coronary angiography showed dissection of the first diagonal branch of the left anterior descending artery, an intermediate lesion in the second obtuse marginal branch of the circumflex artery, and severe stenosis in the right posterior descending artery (Figure 1, arrows). In the diagonal branch, intracoronary ultrasound and optical coherence tomography confirmed intramural hematoma (Figure 2A, asterisks) and an intimal flap (Figure 2A, arrows). Optical coherence tomography revealed an intramural hematoma causing stenosis of the obtuse marginal artery (Figure 2B, asterisk) but this finding was not confirmed in the posterior descending artery due to procedure failure (poor image quality). Two overlapping bioabsorbable stents were implanted in the diagonal side branch, with the end adjusted to the bifurcation. Another 2 overlapping bioabsorbable stents were positioned in the main left anterior descending artery, from the bifurcation along the length of the hematoma. The stents were inflated using the kissing balloon technique (Figure 3). 1 mm

Progressed Multivessel Spontaneous Coronary Artery Dissection That Naturally Healed in a Male Patient with Non-ST Segment Elevation Myocardial Infarction.

Spontaneous coronary artery dissection (SCAD) is a rare condition that may have a serious outcome because of acute coronary syndrome. The condition especially affects young women. We evaluated a middle-aged male patient with a non-ST segment elevation myocardial infarction caused by multivessel SCAD. The SCAD had occurred in the distal right coronary artery (RCA), the mid left anterior descending artery (LAD), and the distal LAD at the same time. His culprit lesion was in the distal RCA, but the SCAD had progressed more proximally within the RCA 12 days later with no clinical symptoms. We treated the mid LAD with implantation of a drug-eluting stent on admission and the SCAD had not progressed 12 days later. Moreover, the SCAD in the distal RCA and distal LAD healed spontaneously 12 days later. He had no recurrent attack, and all SCAD lesions of the RCA and LAD had completely healed 6 months later. Given that SCAD appears in various forms over the clinical course, a strategy of intervention needs careful consideration.