Spontaneous coronary artery dissection: a difficult journey from emergency coronary artery bypass grafting to left
Daniel Ho1,2,3, Ibrahim Alfaris1,2,3,4, Abdulaziz Joury1,2,3,4
1Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, 2155 Rue Guy, Montréal, QC H3H 2L9, Canada.
Insights
Spontaneous coronary artery dissection (SCAD) can cause acute coronary syndrome in young adults. This case highlights advanced interventions like LVAD and OHTx for refractory LMCA SCAD progression and complications.
Area of Science:
- Cardiology
- Vascular Medicine
- Cardiac Surgery
Background:
- Spontaneous Coronary Artery Dissection (SCAD) is an important cause of acute coronary syndrome (ACS) in young adults.
- SCAD pathogenesis involves intramural hematoma formation, potentially leading to severe outcomes like cardiac arrest and arrhythmias.
- Prompt recognition and management are crucial for improving patient outcomes.
Background:
Excluding spontaneous coronary artery dissection (SCAD) as an aetiology 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 electrocardiogram, necessitating high-dose aspirin and urgent transfer to a revascularization centre. Suffering ventricular tachycardia (VT) and ventricular fibrillation (VF), she underwent two rounds of advanced life support and venoarterial extracorporeal membrane oxygenation. Diagnosed with left main coronary artery (LMCA) SCAD, she was initially started on conservative therapy for declining left ventricular ejection fraction. However, she continued 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 of her severe mitral regurgitation. Despite being listed for orthotopic heart transplantation (OHTx), her low body mass index and elevated antibodies necessitated the HeartMate III left ventricular assist device (LVAD) for bridge to transplant. After treating frequent VT episodes with medications, she eventually received a LVAD as a bridge to cardiac transplantation. Within 1 year of her receiving LVAD, she underwent a successful OHTx.
Discussion:
The pathogenesis of SCAD involves intramural haematoma formation through intimal tears or vasa vasorum haemorrhage. Adverse outcomes that could occur in SCAD patients include cardiac arrest, cardiogenic shock, reduced left ventricle systolic function, and occasionally serious cardiac arrhythmia-such as VF-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 be considered in refractory cases.
