JACC: CARDIOVASCULAR INTERVENTIONS

VOL. 7, NO. 10, 2014

ª 2014 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION

ISSN 1936-8798/$36.00

PUBLISHED BY ELSEVIER INC.

http://dx.doi.org/10.1016/j.jcin.2014.04.021

IMAGES IN INTERVENTION

All at Once Multivessel Spontaneous Coronary Artery Dissection With Right Coronary Artery ST-Segment Elevation Myocardial Infarction Muhammad Rizwan Sardar, MD,*y Lauren M. Pieczynski, MD,z Wajeeha Saeed, MD,x Steven M. Domsky, MD,y Timothy A. Shapiro, MD,y Paul Coady, MDy

A

35-year-old woman, 12 days post-partum

the left anterior descending artery, second diagonal

presented to the emergency department

branch, left circumflex, and right coronary artery

from

chest

(RCA). She had complete proximal occlusion of her

discomfort that started the previous night. She

RCA with no collaterals (Figures 1B, 1D, 1F, black ar-

described the chest discomfort discomfort “on-and-

rows, Online Video 1). Percutaneous coronary inter-

her

physician’s

office

with

off”, occurring at rest, and located in the central

vention of the RCA was performed (Figure 1G, black

chest with radiation to the left arm lasting a

arrow). For the remaining affected vessels, a conser-

maximum of 5 min. Initial electrocardiogram showed

vative approach was employed with dual antiplatelet

sinus rhythm left axis deviation with non-specific

therapy, in addition to intravenous heparin and

ST-T wave changes in the inferior leads. Her physical

Eptifibatide for 24 h. During her RCA intervention,

exam showed equal blood pressures in both arms

wire presence in true lumen was confirmed using

(140/75 mm Hg), a pulse of 77 beats/min, and pulse

intravascular ultrasound. Transthoracic echocardio-

oximetry of 95% on room air. There were no obvious

gram showed an ejection fraction of 40% with mod-

Marfanoid features, no murmurs or gallops, and

erate area of apical, inferior, and inferolateral wall

normal jugular venous distention. She underwent a

hypokinesis. The patient remained asymptomatic

computed tomography scan of her chest, which

with stable levels of cardiac biomarkers. At day 3,

showed a low probability of pulmonary embolism.

computed

She had normal basic labs besides the first set of

revealed a calcium score of 0, and renal and carotid

troponin (0.11 ng/ml) and was kept in the hospital

ultrasound demonstrated no evidence of fibromus-

for observation. Three hours later, she had a sudden

cular dysplasia. At day 5, repeat cardiac catheteriza-

onset of similar chest discomfort with diaphoresis

tion

and 12-lead electrocardiogram revealed ST-segment

descending artery, second diagonal, and left circum-

elevations in leads V2 and aVL, with ST-segment de-

flex lesions (Figures 1C, 1E, yellow arrows, Online

pressions in the inferior leads (Figure 1A, red ar-

Video 2) with a patent stent in the RCA. She was dis-

rows). Cardiac catheterization was performed; it

charged on dual antiplatelet and beta-blockers. The

showed spontaneous coronary artery dissection in

patient remained asymptomatic, and a follow-up

tomography

showed

stable

coronary

and

healed

From the *Department of Cardiology, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, New Jersey; yDepartment of Cardiology, Lankenau Medical Center, Thomas Jefferson University, Wynnewood, Pennsylvania; zDepartment of Anesthesia, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; and the xDepartment of Medicine, Albert Einstein College of Medicine, Bronx-Lebanon Hospital Center, Bronx, New York. Dr. Sardar has received speaker’s fees from the Atrial Fibrillation Education Program, North American Center for Continuing Medical Education. Dr. Shapiro receives speaker’s fees from AstraZeneca. All other authors have reported that they have no relationships relevant to this paper to disclose. Manuscript received April 7, 2014; accepted April 10, 2014.

calcium

left

score

anterior

e162

Sardar et al.

JACC: CARDIOVASCULAR INTERVENTIONS VOL. 7, NO. 10, 2014 OCTOBER 2014:e161–2

All at Once

F I G U R E 1 Presentation EKG and Cardiac Catheterization Images

(A) A 12-lead electrocardiogram, 3 h after first presentation reveals left axis deviation, incomplete right bundle branch block, and ST-segment elevations in leads V2 and aVL (red arrows) with reciprocal changes in inferior leads. (B) First cardiac catheterization (CC): The right anterior oblique cranial view shows dissection segments (black arrows) in mid–left anterior descending and second diagonal arteries (Online Video 1). (C) Second CC: The right anterior oblique cranial view shows healed left anterior descending and second diagonal arteries (yellow arrows) with good distal flow. Second CC: (D) At day 5, the right anterior oblique caudal view showings left circumflex dissection (black arrows) and (E) shows the healed left circumflex dissection (yellow arrows) with good distal flow (Online Video 2). (F) Acute obstruction of the RCA on the 1st CC (black arrows) with (G) complete revascularization of the RCA after proximal bare-metal stent. See Online Video 1, first cardiac catheterization; Online Video 2, Day 5 cardiac catheterization or follow-up cardiac catheterization.

echocardiogram 1 month later showed a normal ejection fraction with no wall motion abnormalities.

REPRINT REQUESTS AND CORRESPONDENCE: Dr.

Multivessel spontaneous coronary artery dissection

Muhammad Rizwan Sardar, Department of Car-

is rare (1) and can be fatal (2). Our case demonstrates

diology, Cooper University Hospital, Cooper Medical

the employment of conservative therapy might still

School of Rowan University, 3rd Floor Dorrance, One

be enough for treating a patient with extensive mul-

Cooper Plaza, Camden, New Jersey 08103. E-mail:

tivessel spontaneous coronary artery dissection.

[email protected].

REFERENCES 1. Saw J, Ricci D, Starovoytov A, Fox R, Buller CE. Spontaneous Coronary Artery Dissection: Prevalence of Predisposing Condi-

2. Maqsood K, Badri M, Burke J, et al. Spontaneous coronary dissection presenting with reperfusion arrhythmia: a case report. Case Rep Clin Med 2013;

tions Including Fibromuscular Dysplasia in a Tertiary Center Cohort. J Am Coll Cardiol Intv 2013;6:44–52.

2:215–8.

KEY WORDS coronary artery disease, myocardial infarction, post-partum, spontaneous coronary artery dissection, ST-segment elevation myocardial infarction AP PE NDIX For accompanying videos, please see the online version of this paper.