Ruptured spontaneous coronary artery dissection in a postmenopausal woman | |
DOI: 10.5606/e-cvsi.2014.143 | |
Atike Tekeli Kunt, 1 Serdar Akgün, 2 Koray Ak, 3 Selim İsbir, 3 Sinan Arsan3 | |
1Department of Cardiovascular Surgery, Kocaeli Derince Training and Research Hospital, Kocaeli, Turkey 2Department of Cardiovascular Surgery, Bahçelievler Medicana Hospital, İstanbul, Turkey 3Department of Cardiovascular Surgery, Medical Faculty of Marmara University, İstanbul, Turkey |
|
Keywords: Coronary artery; dissection; spontaneous; rupture | |
Spontaneous coronary artery dissection and rupture are extremely rare conditions. We report a 54-year-old postmenopausal female case of
ruptured spontaneous coronary artery dissection who presented with severe chest pain. No electrocardiographic abnormalities were seen.
Serum troponin level was normal. Although acute aortic dissection was suspected, contrast computed tomography revealed pericardial
effusion. The patient was taken to catheterization laboratory for coronary angiography. Catheterization showed a ruptured spontaneous
dissection of the left anterior descending artery without any other atherosclerotic lesions. She underwent coronary artery bypass grafting.
Spontaneous coronary artery dissection and rupture should be kept in mind in differential diagnosis of chest pain. |
|
Spontaneous coronary artery dissection (SCAD)
and rupture are extremely rare conditions with a
poor prognosis. Ruptured SCAD is often fatal,
unless the patient arrives late and early diagnosis
can be made. It is associated with an increased rate
of cardiac tamponade and requires an urgent bypass
surgery. Mostly, SCAD is seen in young women
(mean age of onset: 35 years) with the left anterior
descending artery (LAD) being the most affected
artery.[1,2] Herein, we present a clinical case of
ruptured SCAD of LAD. |
|
CASE PRESANTATION
|
|
A 54-year-old postmenopausal female patient
was admitted with a severe chest pain. Physical
examination and vital signs were normal on
admission. No electrocardiographic abnormalities
were seen. Serum troponin level was normal.
Contrast computed tomography (CT) was performed
based on the suspicion of acute aortic dissection.
However, CT revealed an isolated pericardial
effusion. The patient was then transferred to
cardiac catheterization laboratory. Catheterization
showed a ruptured spontaneous dissection of LAD
with a double lumen structure without any other
atherosclerotic lesions (Figures 1 and 2). She
was successfully managed with coronary artery
bypass grafting (CABG) where the left internal
thoracic artery was grafted to the LAD with
cardiopulmonary bypass and the proximal LAD
was ligated for bleeding management. Subepicardial hematoma was evacuated. Following a normal
postoperative course, the patient was discharged in
the sixth postoperative day. |
|
Although SCAD is known to be mainly the disease
of young women in the peripartum period, it can be
associated with immunological disorders including
systemic lupus erythematosus, Ehler Danlos syndrome
(type IV) and Kawasaki disease.[1,3] It can also be
seen in middle and older aged men and women
having the risks of atherosclerosis. In our case, the
patient was a 54-year-old postmenopausal woman
having no underlying atherosclerotic coronary
artery disease. Percutaneous coronary interventions,
aneurysm, trauma, Kawasaki disease and SCAD
are the known factors resulting in coronary artery
rupture.[1,3] The clinical presentation of SCAD usually
includes the entire signs and symptoms of acute
coronary syndromes, mostly mimicking myocardial
infarction. However, patients usually present with cardiac tamponade and sudden death, even in case of a
suspected coronary artery rupture. The treatment strategy of SCAD solely depends on the extension of the dissection, involving coronary artery, and most importantly on the clinical presentation and overall health status of the patient. Patients with pericardial effusion or tamponade should be managed with surgery immediately. The selection of the graft and use of cardiopulmonary bypass also depends on the patient. In addition, pregnant women can be successfully managed by off-pump CABG, if surgery is indicated. Other treatment modalities include percutaneous transluminal coronary angioplasty, coronary artery stenting with cover-stents, thrombolytic and medical therapies in patients with SCAD. Spontaneous healing of SCAD has been also reported in the literature.[4-6] In conclusion, although rare, SCAD and rupture should be kept in mind in the differential diagnosis of acute chest pain in adult patients of all ages and sex and should be individually managed.
Declaration of conflicting interests
Funding |
|
1) Celik SK, Sagcan A, Altintig A, Yuksel M, Akin M,
Kultursay H. Primary spontaneous coronary artery
dissections in atherosclerotic patients. Report of nine cases
with review of the pertinent literature. Eur J Cardiothorac
Surg 2001;20:573-6.
2) Sharma AD, Sreeram G, Slaughter TF. Spontaneous
coronary artery dissection in a healthy 24-year-old woman.
J Cardiothorac Vasc Anesth 2000;14:312-3.
3) Atay Y, Yağdi T, Türkoğlu C, Altintiğ A, Büket S.
Spontaneous dissection of the left main coronary artery:
a case report and review of the literature. J Card Surg
1996;11:371-5.
4) Ciraulo DA, Chesne RB. Coronary arterial dissection:
an unrecognized cause of myocardial infarction, with
subsequent coronary arterial patency. Chest 1978;73:677-9.
|
|