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Recurrent coronary artery dissection of left main trunk initially presented with normal coronary angiography
Journal of Cardiology Cases 14 (2016) 164–167
Contents lists available at ScienceDirect
Journal of Cardiology Cases journal homepage: www.elsevier.com/locate/jccase
Case Report
Recurrent coronary artery dissection of left main trunk initially presented with normal coronary angiography Masahiko Shibuya (MD)a, Kenichi Fujii (MD, PhD)b, Takahiro Imanaka (MD)a, Kenji Kawai (MD)a, Tomotaka Ando (MD)a, Hiroto Tamaru (MD)a, Akinori Sumiyoshi (MD)a, Tetsuo Horimatsu (MD)a, Kenki Ashida (MD)a, Ten Saita (MD)a, Kumiko Masai (MD)a, Reiko Yamasaki (MD)a, Shinya Fukui (MD, PhD)c, Yuji Miyamoto (MD, PhD)c, Tohru Masuyama (MD, PhD, FJCC)a, Masaharu Ishihara (MD, PhD, FJCC)a,* a b c
Division of Cardiovascular Medicine and Coronary Heart Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan Department of Cardiology, Higashi-Takarazuka Satoh Hospital, Takarazuka, Japan Department of Cardiovascular Surgery, Hyogo College of Medicine, Nishinomiya, Japan
A R T I C L E I N F O
A B S T R A C T
Article history: Received 20 June 2016 Received in revised form 29 July 2016 Accepted 2 August 2016
Although spontaneous coronary artery dissection (SCAD) is usually diagnosed by coronary angiography, diagnosis may be missed because of various presentations and imperfections of coronary angiography. We report a case of a 41-year-old female with pregnancy-related SCAD who presented with cardiac arrest. Initial coronary angiography was normal without intimal flap. Unexpectedly, 4 days after admission, SCAD in left main trunk was revealed with recurrent myocardial infarction. Intimal flap was sealed at the time of first angiography and this is an interesting point that made us report this case. SCAD is a rare but not negligible cause of not only acute myocardial infarction but also sudden cardiac arrest even if first coronary angiography is normal. ß 2016 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.
Keywords: Spontaneous coronary artery dissection Sudden cardiac arrest Left main coronary artery Post-partum Acute coronary syndrome
Introduction
Case report
Spontaneous coronary artery dissection (SCAD) is a rare cause of acute myocardial infarction (AMI) [1–3]. SCAD is usually diagnosed by coronary angiography, but diagnosis may be missed because of various presentations of SCAD and imperfections of coronary angiography. We describe a case of a 41-year-old female with pregnancy-related SCAD in left main trunk (LMT) who initially presented with normal angiography.
A 41-year-old woman without medical history was found with pulseless electrical activity 10 days after childbirth. After cardiopulmonary resuscitation, return of spontaneous circulation was obtained. She was transferred to our hospital immediately. At the time of hospital admission, her consciousness was not disturbed and she was free from subjective symptoms. Her vital signs and physical examination revealed no abnormalities. The initial electrocardiogram showed ST-segment depression in leads II, III, and aVF. The initial electrocardiogram showed ST-segment depression in leads II, III, aVF and slight ST elevation and inverted T wave in aVR, V2 to V4 (Fig. 1A). Echocardiography was normal without regional wall motion abnormalities. We performed emergency coronary angiography to rule out coronary artery disease as a possible cause of sudden cardiac arrest. Coronary
* Corresponding author at: Division of Coronary Heart Disease, Department of Internal Medicine, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya City, Hyogo 6638501, Japan. Fax: +81 798 45 6551. E-mail address: [email protected] (M. Ishihara).
http://dx.doi.org/10.1016/j.jccase.2016.08.004 1878-5409/ß 2016 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.
M. Shibuya et al. / Journal of Cardiology Cases 14 (2016) 164–167
Fig. 1.
The initial electrocardiogram showed ST-segment depression in leads II, III, aVF and slight ST elevation and inverted T wave in aVR, V2 to V4 (A). Electrocardiogram immediately after initial coronary angiography demonstrated baseline ST level in lead V2 to V4 (B). ST-segment elevation was seen at V2 to V4 on the 4th day (C).
angiography showed normal coronary artery without stenosis, flow delay, or dissection (Fig. 2). Additional studies including spasm provocation test and intracoronary imaging were not performed. Electrocardiogram immediately after initial coronary angiography demonstrated baseline ST level in lead V2 to V4 (Fig. 1B). The patient was transferred to the coronary care unit. Although etiology of sudden cardiac arrest was unknown, she was
Fig. 2.
165
managed with beta-blocker and intravenous nitroglycerine and her clinical course was stable. On the 4th day, she suddenly complained of prolonged chest pain. Electrocardiogram showed ST-segment elevation at V2 to V4 (Fig. 1C). Severe hypo-kinesis of left ventricular anterior and apical wall appeared on echocardiography. Then, the second emergent coronary angiography was performed and it revealed total occlusion of the proximal left
Coronary angiography demonstrated normal coronary artery without dissection. Panels A (Movie 1), B (Movie 2), C (Movie 3), D (Movie 4), and E (Movie 5) showed coronary angiography in right anterior oblique (RAO)-cranial view, anteroposterior (AP)-cranial view, left anterior oblique (LAO)-cranial view, RAOcaudal view, and LAO-caudal view, respectively.
166
Fig. 3.
M. Shibuya et al. / Journal of Cardiology Cases 14 (2016) 164–167
The second emergent coronary angiography revealed total occlusion of the proximal left anterior descending (LAD) artery caused by large dissection extending from left main trunk. Spiral dissection was also observed in the proximal to mid segment of the left circumflex artery (LCX) in anteroposterior (AP)-caudal view (A). With an instant delay, contrast medium rushed into distal LAD (B). Repeated left coronary angiography showed subtotal occlusion of LCX and patent LAD without flow delay in AP-cranial views (C). Final coronary angiography from left coronary cusp showed no visible dissection in left main trunk, patent LAD, and severe stenosis in the mid LCX without flow delay in AP-caudal view (D).
anterior descending (LAD) artery caused by large dissection extending from LMT. Spiral dissection was also observed in the proximal to mid segment of the left circumflex artery (LCX) (Fig. 3A). With an instant delay, contrast medium rushed into distal LAD (Fig. 3B). The right coronary artery was normal. During coronary angiography, her hemodynamic state was unstable. Repeated coronary angiography showed patent LAD without delay, but LCX showed subtotal occlusion (Fig. 3C). After initiation of intra-aortic balloon pumping, her hemodynamics became stable. Final coronary angiography from left coronary cusp showed no visible dissection in LMT, patent LAD, and severe stenosis in the mid LCX without flow delay (Fig. 3D). We held a heart-team conference with cardiac surgeons and emergent coronary artery bypass graft surgery was offered. Saphenous vein grafts (SVGs) were used for LAD and LCX. Post-operative course was uneventful. At day 17, she underwent coronary angiography. The coronary angiography revealed native LAD and LCX flows competed with preserved bypass flow in both SVG-LAD and SVG-LCX. Moderate stenosis was seen in native mid LCX. Dissections were not clearly seen (Fig. 4). She was discharged from hospital on the 30th day. In this case, making a diagnosis of SCAD was difficult at initial coronary angiography because intimal flap was completely sealed without stenosis or flow delay. That is the interesting point that made us report this case.
Discussion SCAD is a spontaneous separation of coronary artery wall by intramural hemorrhage, causing lumen occlusion subsequently compressing arterial lumen. It often occurs during the perinatal period. This is a case of a young post-partum woman with resuscitated sudden cardiac arrest. Initial coronary angiography could not detect coronary dissection or intimal flap that led to delay in diagnosis. SCAD is often missed when dissection or contrast stain is not present on coronary angiography. Saw characterized three distinct angiographic appearances and proposed a classification of SCAD [4]. Type 2 SCAD (diffuse stenosis of varying severity) or Type 3 (mimic atherosclerosis) is often missed because there is no flap or contrast staining and the abrupt change in arterial caliper is often subtle. In this case, to diagnose SCAD at initial coronary angiography was difficult because intimal flap was completely sealed without stenosis or flow delay. Alfonso et al. have reported that only 3 out of 11 patients who were diagnosed as having SCAD by optical coherence tomography presented with an intimal flap on angiography [5]. SCAD revealed the diversity of the symptoms and angiographic findings. These are possibly misdiagnosed due to the imperfections of coronary angiography. As shown in Fig. 2
M. Shibuya et al. / Journal of Cardiology Cases 14 (2016) 164–167
Fig. 4.
167
Post-coronary artery bypass graft, coronary angiography demonstrated preserved saphenous vein graft (SVG)-left anterior descending artery (LAD) in left anterior oblique (LAO) view (A), patent SVG-left circumflex artery (LCX) in anteroposterior (AP)-caudal view (B). Native LAD and LCX flows competed with preserved bypass flow in both SVG-LAD and SVG-LCX in AP-caudal view (C) and LAO-caudal view (D). Moderate stenosis was seen in native mid LCX.
and Movies 1–5, the patient underwent angiography by several views, and there was no clear evidence of SCAD. Despite us being aware of the possibility of SCAD as a cause of cardiac arrest, we could not detect dissection on the initial coronary angiography even after intensive review by expert interventional cardiologists. Other modalities such as intravascular ultrasound or optical coherence tomography should be considered to use even when there is no suspicion of SCAD at the first angiography. Ito et al. have reported that prognosis of post-partum SCAD was poor because of proximal segment involvement and large infarct size [6]. They recommended a second-look coronary angiogram during the index hospitalization especially if the primary dissection is located in the proximal LAD or LCX because the further extension of SCAD or new dissection in a remote coronary site was observed in 26% of the patients during hospitalization. Even though the patient presented with normal coronary artery, SCAD should be included as the differential diagnosis in a case of a young postpartum woman with resuscitated sudden cardiac arrest. We should be aware that SCAD is a rare but not negligible cause of sudden cardiac arrest even if initial coronary angiography is normal. Supplementary Movies 1–5 related to this article can be found, in the online version, at http://dx.doi.org/10.1016/j.jccase.2016.08. 004.
Conclusion SCAD is a rare but not negligible cause of not only AMI but also sudden cardiac arrest even if initial angiography is normal. Conflict of interest None. References [1] Bergen E, Huffer L, Peele M. Survival after spontaneous coronary artery dissection presenting with ventricular fibrillation arrest. J Invasive Cardiol 2005;17:E4–6. [2] Mortensen KH, Thuesen L, Kristensen IB, Christiansen EH. Spontaneous coronary artery dissection: a Western Denmark Heart Registry study. Catheter Cardiovasc Interv 2009;74:710–7. [3] Basso C, Morgagni GL, Thiene G. Spontaneous coronary artery dissection: a neglected cause of acute myocardial ischaemia and sudden death. Heart 1996;75:451–4. [4] Saw J. Coronary angiogram classification of spontaneous coronary artery dissection. Catheter Cardiovasc Interv 2014;84:1115–22. [5] Alfonso F, Paulo M, Gonzalo N, Dutary J, Jimenez-Quevedo P, Lennie V, Escaned J, ˜ uelos C, Hernandez R, Macaya C. Diagnosis of spontaneous coronary artery Ban dissection by optical coherence tomography. J Am Coll Cardiol 2012;59:1073–9. [6] Ito H, Taylor L, Bowman M, Fry ET, Hermiller JB, Van Tassel JW. Presentation and therapy of spontaneous coronary artery dissection and comparisons of postpartum versus nonpostpartum cases. Am J Cardiol 2011;107:1590–6.
Contents lists available at ScienceDirect
Journal of Cardiology Cases journal homepage: www.elsevier.com/locate/jccase
Case Report
Recurrent coronary artery dissection of left main trunk initially presented with normal coronary angiography Masahiko Shibuya (MD)a, Kenichi Fujii (MD, PhD)b, Takahiro Imanaka (MD)a, Kenji Kawai (MD)a, Tomotaka Ando (MD)a, Hiroto Tamaru (MD)a, Akinori Sumiyoshi (MD)a, Tetsuo Horimatsu (MD)a, Kenki Ashida (MD)a, Ten Saita (MD)a, Kumiko Masai (MD)a, Reiko Yamasaki (MD)a, Shinya Fukui (MD, PhD)c, Yuji Miyamoto (MD, PhD)c, Tohru Masuyama (MD, PhD, FJCC)a, Masaharu Ishihara (MD, PhD, FJCC)a,* a b c
Division of Cardiovascular Medicine and Coronary Heart Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan Department of Cardiology, Higashi-Takarazuka Satoh Hospital, Takarazuka, Japan Department of Cardiovascular Surgery, Hyogo College of Medicine, Nishinomiya, Japan
A R T I C L E I N F O
A B S T R A C T
Article history: Received 20 June 2016 Received in revised form 29 July 2016 Accepted 2 August 2016
Although spontaneous coronary artery dissection (SCAD) is usually diagnosed by coronary angiography, diagnosis may be missed because of various presentations and imperfections of coronary angiography. We report a case of a 41-year-old female with pregnancy-related SCAD who presented with cardiac arrest. Initial coronary angiography was normal without intimal flap. Unexpectedly, 4 days after admission, SCAD in left main trunk was revealed with recurrent myocardial infarction. Intimal flap was sealed at the time of first angiography and this is an interesting point that made us report this case. SCAD is a rare but not negligible cause of not only acute myocardial infarction but also sudden cardiac arrest even if first coronary angiography is normal.
Keywords: Spontaneous coronary artery dissection Sudden cardiac arrest Left main coronary artery Post-partum Acute coronary syndrome
Introduction
Case report
Spontaneous coronary artery dissection (SCAD) is a rare cause of acute myocardial infarction (AMI) [1–3]. SCAD is usually diagnosed by coronary angiography, but diagnosis may be missed because of various presentations of SCAD and imperfections of coronary angiography. We describe a case of a 41-year-old female with pregnancy-related SCAD in left main trunk (LMT) who initially presented with normal angiography.
A 41-year-old woman without medical history was found with pulseless electrical activity 10 days after childbirth. After cardiopulmonary resuscitation, return of spontaneous circulation was obtained. She was transferred to our hospital immediately. At the time of hospital admission, her consciousness was not disturbed and she was free from subjective symptoms. Her vital signs and physical examination revealed no abnormalities. The initial electrocardiogram showed ST-segment depression in leads II, III, and aVF. The initial electrocardiogram showed ST-segment depression in leads II, III, aVF and slight ST elevation and inverted T wave in aVR, V2 to V4 (Fig. 1A). Echocardiography was normal without regional wall motion abnormalities. We performed emergency coronary angiography to rule out coronary artery disease as a possible cause of sudden cardiac arrest. Coronary
* Corresponding author at: Division of Coronary Heart Disease, Department of Internal Medicine, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya City, Hyogo 6638501, Japan. Fax: +81 798 45 6551. E-mail address: [email protected] (M. Ishihara).
http://dx.doi.org/10.1016/j.jccase.2016.08.004 1878-5409/ß 2016 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.
M. Shibuya et al. / Journal of Cardiology Cases 14 (2016) 164–167
Fig. 1.
The initial electrocardiogram showed ST-segment depression in leads II, III, aVF and slight ST elevation and inverted T wave in aVR, V2 to V4 (A). Electrocardiogram immediately after initial coronary angiography demonstrated baseline ST level in lead V2 to V4 (B). ST-segment elevation was seen at V2 to V4 on the 4th day (C).
angiography showed normal coronary artery without stenosis, flow delay, or dissection (Fig. 2). Additional studies including spasm provocation test and intracoronary imaging were not performed. Electrocardiogram immediately after initial coronary angiography demonstrated baseline ST level in lead V2 to V4 (Fig. 1B). The patient was transferred to the coronary care unit. Although etiology of sudden cardiac arrest was unknown, she was
Fig. 2.
165
managed with beta-blocker and intravenous nitroglycerine and her clinical course was stable. On the 4th day, she suddenly complained of prolonged chest pain. Electrocardiogram showed ST-segment elevation at V2 to V4 (Fig. 1C). Severe hypo-kinesis of left ventricular anterior and apical wall appeared on echocardiography. Then, the second emergent coronary angiography was performed and it revealed total occlusion of the proximal left
Coronary angiography demonstrated normal coronary artery without dissection. Panels A (Movie 1), B (Movie 2), C (Movie 3), D (Movie 4), and E (Movie 5) showed coronary angiography in right anterior oblique (RAO)-cranial view, anteroposterior (AP)-cranial view, left anterior oblique (LAO)-cranial view, RAOcaudal view, and LAO-caudal view, respectively.
166
Fig. 3.
M. Shibuya et al. / Journal of Cardiology Cases 14 (2016) 164–167
The second emergent coronary angiography revealed total occlusion of the proximal left anterior descending (LAD) artery caused by large dissection extending from left main trunk. Spiral dissection was also observed in the proximal to mid segment of the left circumflex artery (LCX) in anteroposterior (AP)-caudal view (A). With an instant delay, contrast medium rushed into distal LAD (B). Repeated left coronary angiography showed subtotal occlusion of LCX and patent LAD without flow delay in AP-cranial views (C). Final coronary angiography from left coronary cusp showed no visible dissection in left main trunk, patent LAD, and severe stenosis in the mid LCX without flow delay in AP-caudal view (D).
anterior descending (LAD) artery caused by large dissection extending from LMT. Spiral dissection was also observed in the proximal to mid segment of the left circumflex artery (LCX) (Fig. 3A). With an instant delay, contrast medium rushed into distal LAD (Fig. 3B). The right coronary artery was normal. During coronary angiography, her hemodynamic state was unstable. Repeated coronary angiography showed patent LAD without delay, but LCX showed subtotal occlusion (Fig. 3C). After initiation of intra-aortic balloon pumping, her hemodynamics became stable. Final coronary angiography from left coronary cusp showed no visible dissection in LMT, patent LAD, and severe stenosis in the mid LCX without flow delay (Fig. 3D). We held a heart-team conference with cardiac surgeons and emergent coronary artery bypass graft surgery was offered. Saphenous vein grafts (SVGs) were used for LAD and LCX. Post-operative course was uneventful. At day 17, she underwent coronary angiography. The coronary angiography revealed native LAD and LCX flows competed with preserved bypass flow in both SVG-LAD and SVG-LCX. Moderate stenosis was seen in native mid LCX. Dissections were not clearly seen (Fig. 4). She was discharged from hospital on the 30th day. In this case, making a diagnosis of SCAD was difficult at initial coronary angiography because intimal flap was completely sealed without stenosis or flow delay. That is the interesting point that made us report this case.
Discussion SCAD is a spontaneous separation of coronary artery wall by intramural hemorrhage, causing lumen occlusion subsequently compressing arterial lumen. It often occurs during the perinatal period. This is a case of a young post-partum woman with resuscitated sudden cardiac arrest. Initial coronary angiography could not detect coronary dissection or intimal flap that led to delay in diagnosis. SCAD is often missed when dissection or contrast stain is not present on coronary angiography. Saw characterized three distinct angiographic appearances and proposed a classification of SCAD [4]. Type 2 SCAD (diffuse stenosis of varying severity) or Type 3 (mimic atherosclerosis) is often missed because there is no flap or contrast staining and the abrupt change in arterial caliper is often subtle. In this case, to diagnose SCAD at initial coronary angiography was difficult because intimal flap was completely sealed without stenosis or flow delay. Alfonso et al. have reported that only 3 out of 11 patients who were diagnosed as having SCAD by optical coherence tomography presented with an intimal flap on angiography [5]. SCAD revealed the diversity of the symptoms and angiographic findings. These are possibly misdiagnosed due to the imperfections of coronary angiography. As shown in Fig. 2
M. Shibuya et al. / Journal of Cardiology Cases 14 (2016) 164–167
Fig. 4.
167
Post-coronary artery bypass graft, coronary angiography demonstrated preserved saphenous vein graft (SVG)-left anterior descending artery (LAD) in left anterior oblique (LAO) view (A), patent SVG-left circumflex artery (LCX) in anteroposterior (AP)-caudal view (B). Native LAD and LCX flows competed with preserved bypass flow in both SVG-LAD and SVG-LCX in AP-caudal view (C) and LAO-caudal view (D). Moderate stenosis was seen in native mid LCX.
and Movies 1–5, the patient underwent angiography by several views, and there was no clear evidence of SCAD. Despite us being aware of the possibility of SCAD as a cause of cardiac arrest, we could not detect dissection on the initial coronary angiography even after intensive review by expert interventional cardiologists. Other modalities such as intravascular ultrasound or optical coherence tomography should be considered to use even when there is no suspicion of SCAD at the first angiography. Ito et al. have reported that prognosis of post-partum SCAD was poor because of proximal segment involvement and large infarct size [6]. They recommended a second-look coronary angiogram during the index hospitalization especially if the primary dissection is located in the proximal LAD or LCX because the further extension of SCAD or new dissection in a remote coronary site was observed in 26% of the patients during hospitalization. Even though the patient presented with normal coronary artery, SCAD should be included as the differential diagnosis in a case of a young postpartum woman with resuscitated sudden cardiac arrest. We should be aware that SCAD is a rare but not negligible cause of sudden cardiac arrest even if initial coronary angiography is normal. Supplementary Movies 1–5 related to this article can be found, in the online version, at http://dx.doi.org/10.1016/j.jccase.2016.08. 004.
Conclusion SCAD is a rare but not negligible cause of not only AMI but also sudden cardiac arrest even if initial angiography is normal. Conflict of interest None. References [1] Bergen E, Huffer L, Peele M. Survival after spontaneous coronary artery dissection presenting with ventricular fibrillation arrest. J Invasive Cardiol 2005;17:E4–6. [2] Mortensen KH, Thuesen L, Kristensen IB, Christiansen EH. Spontaneous coronary artery dissection: a Western Denmark Heart Registry study. Catheter Cardiovasc Interv 2009;74:710–7. [3] Basso C, Morgagni GL, Thiene G. Spontaneous coronary artery dissection: a neglected cause of acute myocardial ischaemia and sudden death. Heart 1996;75:451–4. [4] Saw J. Coronary angiogram classification of spontaneous coronary artery dissection. Catheter Cardiovasc Interv 2014;84:1115–22. [5] Alfonso F, Paulo M, Gonzalo N, Dutary J, Jimenez-Quevedo P, Lennie V, Escaned J, ˜ uelos C, Hernandez R, Macaya C. Diagnosis of spontaneous coronary artery Ban dissection by optical coherence tomography. J Am Coll Cardiol 2012;59:1073–9. [6] Ito H, Taylor L, Bowman M, Fry ET, Hermiller JB, Van Tassel JW. Presentation and therapy of spontaneous coronary artery dissection and comparisons of postpartum versus nonpostpartum cases. Am J Cardiol 2011;107:1590–6.