Recurrent Spontaneous Coronary Artery Dissection Leading to Advanced Heart Failure and LVAD Implantation

Spontaneous coronary artery dissection (SCAD) is an important cause of acute myocardial infarction in women without significant atherosclerotic coronary artery disease. Recurrent SCAD progressing to advanced heart failure requiring durable mechanical circulatory support is exceptionally uncommon. A 45-year-old woman with a mechanical mitral valve prosthesis presented with non-ST-segment elevation myocardial infarction caused by multivessel SCAD involving the circumflex artery (Type 1) and the first obtuse marginal branch (OM1) (Type 2A). Because coronary flow was preserved (TIMI 3), conservative management was adopted. Follow-up angiography demonstrated healing of the OM1 lesion and a stable residual circumflex dissection. Two years later, she presented with anterior ST-segment elevation myocardial infarction. Coronary angiography demonstrated an abrupt, near-total occlusion of the left anterior descending artery, which was considered most compatible with recurrent Type 4 SCAD after alternative diagnoses, including coronary thromboembolism, were excluded. Despite intracoronary vasodilator therapy, persistent ischemia necessitated percutaneous coronary intervention with drug-eluting stent implantation, restoring TIMI 3 flow. Severe left ventricular systolic dysfunction developed despite successful revascularization and optimal medical therapy. During follow-up, the patient underwent implantation of an implantable cardioverter-defibrillator (ICD) for primary prevention and, after recurrent heart failure hospitalizations over 18 months, durable left ventricular assist device (LVAD) implantation as a bridge to heart transplantation. This case demonstrates that angiographic healing after conservatively managed SCAD does not eliminate the risk of recurrence in previously unaffected coronary territories. It underscores the diagnostic challenges of Type 4 SCAD in patients with competing causes of myocardial infarction and illustrates that recurrent SCAD may rarely progress to advanced heart failure requiring durable mechanical circulatory support.