- Email: [email protected]
Transesophageal echo detection of postpartum coronary artery dissection
CASE REPORTS
Transesophageal Echo Detection of Postpartum Coronary Artery Dissection Stamatios Lerakis, MD, Steven Manoukian, MD, and Randolph P. Martin, MD, FACC, Atlanta, Georgia
A 40-year-old woman, 1 week postpartum, presented with an acute anterior-septal myocardial infarction, caused b y an intrawaU hematoma (dissection without intimal flap) in her proximal left anterior de-
Spontaneous
dissection of a coronary artery is a rare occurrence. Myocardial infarction in the peripartum period is also rare, but in more than 50% of the cases, the cause is coronary artery dissection. 1 We report the first case of a postpartum coronary artery dissection diagnosed by transesophageal echocardiogram (TEE) and subsequently confirmed by cardiac catheterization. A 40-year-old white w o m a n G2P2, 1 week postpartum, awoke with severe chest pain and diaphoresis. As e m e r g e n c y medical p e r s o n n e l arrived at her home, the patient developed full cardiac arrest with ventricular fibrillation and was successfully resuscitated.The patient was transported to a local hospital, and then transferred to our institution. On arrival in the emergency department, her ECG showed anterior-septal ST-segment elevation compatible with an acute anterior infarction.The patient was intubated. Her blood pressure was 130/86 in both arms, pulse was regular at 104 bpm, and respiratory rate was 17 on mechanical ventilation. The remainder of the physical examination was unremarkable. A chest xray film showed no active disease.The peak creatine phosphokinase was 3847 U/L (normal range 38-234) with creatine kinase myocardial bound 228 ng/mL (normal range < 5) and creatine kinase index 5.9 (normal range < 2.5). The patient had no significant past medical history, no history of smoking, and no family history of coro-
From the Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia. Reprint requests: Randolph P. Martin, MD, FACC, Director of Noninvasive Cardiology,D433 Emory University Hospital, 1364 Clifton Rd, NE, Adanta, GA 30322. Copyright © 2001 by the American Societyof Echocardiography. 0894-7317/2001/$35.00 + 0 27/4/115654 doi:10.1067/mje.2001.115654 1132
scending c o r o n a r y a r t e r y - - t h e diagnosis being initially suggested by transesophageal echo. Discussion of this entity follows. (J Am Soc Echocardiogr 2001;14:1132-3.)
nary artery disease. Soon after arrival in the Coronary Care Unit, a transesophageal echo was performed to rule out the remote possibility of aortic root dissection.The TEE showed no aortic dissection, but there was severe hypokinesis of the anterior-septal wall, with a left ventricular ejection fraction estimated at 30%. Of note was prominent thickening of the wall of the proximal left anterior descending (LAD) coronary artery, seen at about 30 degrees at the aortic valve level with a hypoechoic linear density in the wall, which raised the question of a dissection without intimal flap (Figure 1). On the basis of these fmdings, the patient underwent cardiac catheterization, which demonstrated a luminal irregularity in the proximal LAD without any o t h e r c o r o n a r y lesions. The left ventriculogram showed moderate to severe anterior-septal hypokinesis with estimated ejection fraction of 30%. The patient was treated with intravenous heparin, nitroglycerin drip, aspirin, beta-blocker, and angiotensin converting enzyme inhibitor, as well as coumadin. The patient initially did well and was extubated; however, 3 days after admission, severe substernal chest pain, with ST elevation, again developed and she underwent repeat cardiac catheterization. This showed a total occlusion of the proximal LAD in the area of the previous luminal irregularity and supposed LAD dissection. She underwent stent placement and was placed on heparin, tirofiban, and ticlodipine for the next 2 days. The patient was discharged 3 days later, has undergone an uneventful cardiac rehabilitation, and leads a normal lifestyle. Myocardial infarction in young w o m e n under the age of 40 is most often a result of coronary atherosclerotic heart disease. 2 Myocardial infarction has occurred in pregnant w o m e n at all stages of pregnancy, with the most c o m m o n cause being occlusive
Journal of the American Society of Echocardiography Volume 14 Number 11
c o r o n a r y a r t e r y disease. 2 In t h e series b y Roth a n d Elkayam, 3 43% o f t h e w o m e n w i t h m y o c a r d i a l infarction d u r i n g p r e g n a n c y w e r e f o u n d to have c o r o n a r y atherosclerosis with or without intracoronary thrombus, 21% h a d c o r o n a r y t h r o m b u s only, 16% h a d coron a r y dissection, a n d 29% h a d n o r m a l c o r o n a r i e s . T h e c u m u l a t i v e m a t e r n a l m o r t a l i t y in this series w a s 21%, w i t h t h e r a t e s in t h e p e r i p a r t u m a n d p o s t p a r t u m p e r i o d b e i n g m u c h h i g h e r t h a n t h o s e in t h e anteparturn p e r i o d . C o r o n a r y a r t e r y d i s s e c t i o n a s s o c i a t e d w i t h pregn a n c y o c c u r s m o s t c o m m o n l y d u r i n g t h e t h i r d trim e s t e r o r t h e early p o s t p a r t u m p e r i o d 4 a n d unfortun a t e l y has a dismal p r o g n o s i s . 5 C o r o n a r y a r t e r y diss e c t i o n in t h e p e r i p a r t u m p e r i o d is n o t g e n e r a l l y a s s o c i a t e d w i t h m a t e r n a l h y p e r t e n s i o n o r significant atherosclerosis.5 T h e p a t h o g e n e s i s o f t h i s e n t i t y is u n k n o w n . H o w e v e r , t h e LAD c o r o n a r y a r t e r y is t h e m o s t c o m m o n l y affected vessel. O f f u r t h e r i n t e r e s t is t h e fact t h a t t h e d i s s e c t i o n m o s t often involves t h e p r o x i m a l 2 c m o f t h e LAD. Pathologic e x a m i n a t i o n has r e v e a l e d d e g e n e r a t i v e m o r p h o l o g i c c h a n g e s in t h e a r t e r i a l wall, w i t h a n a c c u m u l a t i o n o f a m o r p h o u s i n t e r c e l l u l a r m a t e r i a l at t h e d i s s e c t i o n site. T h e s e c h a n g e s are b e l i e v e d to b e m o s t likely i n d u c e d b y h o r m o n a l c h a n g e s surrounding t h e p e r i p a r t u m p e r i o d . 6 T h e h e m a t o m a s are usually c o n f m e d to t h e media, w i t h o u t e v i d e n c e o f an intimal tear, l e a d i n g s o m e to believe that t h e h e m o d y n a m i c s t r e s s e s r e l a t e d to p r e g n a n c y , labor, a n d d e l i v e r y m a y also lead to a loss o f structural i n t e g r i t y o f t h e b l o o d vessel wall. T h e diagnosis o f p e r i p a r t u m c o r o n a r y d i s s e c t i o n in m o s t i n s t a n c e s has b e e n e s t a b l i s h e d p o s t m o r t e m . This is t h e first c a s e o f c o r o n a r y a r t e r y d i s s e c t i o n d e t e c t e d b y TEE in a w o m a n in h e r p e r i p a r t u m perio d . J a k o b et al 7 r e p o r t e d a p a t i e n t w h o w a s a d m i t t e d to t h e h o s p i t a l after c o l l a p s e w i t h r e t r o g r a d e amnesia. T h e TEE s h o w e d a d i s s e c t i o n w i t h i n t h e a o r t i c root, which was extending into the ostium and l u m e n o f t h e left m a i n c o r o n a r y artery. TEE-detected c o r o n a r y a r t e r y d i s s e c t i o n has also b e e n r e p o r t e d b y C h e r n g et al8 o n a p a t i e n t h a v i n g s u s t a i n e d a b l u n t c h e s t trauma. T h e TEE s h o w e d a s h o r t intimal flap l o c a t e d in t h e p r o x i m a l LAD. S p o n t a n e o u s c o r o n a r y a r t e r y dissection is a p o t e n tially c a t a s t r o p h i c event that is a rare c o m p l i c a t i o n of pregnancy. In this case,TEE w a s successful n o t only in ruling o u t aortic dissection, b u t also in identifying dissection o f t h e p r o x i m a l LAD as well as assessing global a n d r e g i o n a l left v e n t r i c u l a r function. TEE allows imaging o f the left m a i n and p r o x i m a l LAD in the vast m a j o r i t y o f p a t i e n t s . In t h e p r o p e r clinical setting,
Lerakis, Manoukian, Martin 1133
g
Figure 1 Magnified view of LAD artery (white arrows) showing very thick wall with narrowed lumen. This view was taken at level o f aortic vane with angle of interrogation being 30%.
m e t i c u l o u s attention should b e p a i d to t h e thickness o f the walls of t h e p r o x i m a l LAD, as the unusual thickening and h y p o e c h o i c nature o f t h e wall, in t h e p r o p er clinical setting, strongly l e d to t h e s u s p i c i o n o f a c o r o n a r y a r t e r y dissection. Careful e x a m i n a t i o n a n d m e t i c u l o u s o b s e r v a t i o n o f all cardiac and extracardiac s t r u c t u r e s d u r i n g TEE c a n significantly i m p a c t t h e m a n a g e m e n t o f critically ill patients.
REFERENCES
1. Hoppe UC, Beuckelmann DJ, Bohm M, Erdmann E. A young mother with severe chest pain. Heart 1998;79:205. 2. Morris CD, Hurst JW, Logue RB. Myocardial infarction in young women. Am J Cardiol 1976;38:299-304. 3. Roth A, Elkavam U. Acute myocardial infarction associated with pregnacy. Ann Intern Med 1996;125:751-62. 4. Vicari R, Eybel C, Monson D. Survival following spontaneous coronary artery dissection: surgical repair by extrusion of intramural hematoma. Am Heart J 1986;111:593-4. 5. Engelman DT, Thayer J, Derossi J, Scheinerman ], Brown L. Pregnancy related coronary artery dissection: a case report and collective review. Conn Med 1993;57:135-9. 6. Sage MD, Koelmeyer TD, Smeeton WM. Fatal postpartum coronary artery dissection-a light-and electron-microscope study. Am J Forensic Med Pathol 1986;7:107-11. 7. Jakob M, Ritter M, Rickli H, Jenni R. Transesophageal colour Doppler detection of coronary artery dissection. Lancet 1994;343:1574-5. 8. Cherng W, Bullard MJ, Chang H, Lin F. Diagnosis of coronary dissection following blunt trauma by transesophageal echocardiography. J Trauma Injury Infect Crit Care 1995;39:
772-4.
Transesophageal Echo Detection of Postpartum Coronary Artery Dissection Stamatios Lerakis, MD, Steven Manoukian, MD, and Randolph P. Martin, MD, FACC, Atlanta, Georgia
A 40-year-old woman, 1 week postpartum, presented with an acute anterior-septal myocardial infarction, caused b y an intrawaU hematoma (dissection without intimal flap) in her proximal left anterior de-
Spontaneous
dissection of a coronary artery is a rare occurrence. Myocardial infarction in the peripartum period is also rare, but in more than 50% of the cases, the cause is coronary artery dissection. 1 We report the first case of a postpartum coronary artery dissection diagnosed by transesophageal echocardiogram (TEE) and subsequently confirmed by cardiac catheterization. A 40-year-old white w o m a n G2P2, 1 week postpartum, awoke with severe chest pain and diaphoresis. As e m e r g e n c y medical p e r s o n n e l arrived at her home, the patient developed full cardiac arrest with ventricular fibrillation and was successfully resuscitated.The patient was transported to a local hospital, and then transferred to our institution. On arrival in the emergency department, her ECG showed anterior-septal ST-segment elevation compatible with an acute anterior infarction.The patient was intubated. Her blood pressure was 130/86 in both arms, pulse was regular at 104 bpm, and respiratory rate was 17 on mechanical ventilation. The remainder of the physical examination was unremarkable. A chest xray film showed no active disease.The peak creatine phosphokinase was 3847 U/L (normal range 38-234) with creatine kinase myocardial bound 228 ng/mL (normal range < 5) and creatine kinase index 5.9 (normal range < 2.5). The patient had no significant past medical history, no history of smoking, and no family history of coro-
From the Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia. Reprint requests: Randolph P. Martin, MD, FACC, Director of Noninvasive Cardiology,D433 Emory University Hospital, 1364 Clifton Rd, NE, Adanta, GA 30322. Copyright © 2001 by the American Societyof Echocardiography. 0894-7317/2001/$35.00 + 0 27/4/115654 doi:10.1067/mje.2001.115654 1132
scending c o r o n a r y a r t e r y - - t h e diagnosis being initially suggested by transesophageal echo. Discussion of this entity follows. (J Am Soc Echocardiogr 2001;14:1132-3.)
nary artery disease. Soon after arrival in the Coronary Care Unit, a transesophageal echo was performed to rule out the remote possibility of aortic root dissection.The TEE showed no aortic dissection, but there was severe hypokinesis of the anterior-septal wall, with a left ventricular ejection fraction estimated at 30%. Of note was prominent thickening of the wall of the proximal left anterior descending (LAD) coronary artery, seen at about 30 degrees at the aortic valve level with a hypoechoic linear density in the wall, which raised the question of a dissection without intimal flap (Figure 1). On the basis of these fmdings, the patient underwent cardiac catheterization, which demonstrated a luminal irregularity in the proximal LAD without any o t h e r c o r o n a r y lesions. The left ventriculogram showed moderate to severe anterior-septal hypokinesis with estimated ejection fraction of 30%. The patient was treated with intravenous heparin, nitroglycerin drip, aspirin, beta-blocker, and angiotensin converting enzyme inhibitor, as well as coumadin. The patient initially did well and was extubated; however, 3 days after admission, severe substernal chest pain, with ST elevation, again developed and she underwent repeat cardiac catheterization. This showed a total occlusion of the proximal LAD in the area of the previous luminal irregularity and supposed LAD dissection. She underwent stent placement and was placed on heparin, tirofiban, and ticlodipine for the next 2 days. The patient was discharged 3 days later, has undergone an uneventful cardiac rehabilitation, and leads a normal lifestyle. Myocardial infarction in young w o m e n under the age of 40 is most often a result of coronary atherosclerotic heart disease. 2 Myocardial infarction has occurred in pregnant w o m e n at all stages of pregnancy, with the most c o m m o n cause being occlusive
Journal of the American Society of Echocardiography Volume 14 Number 11
c o r o n a r y a r t e r y disease. 2 In t h e series b y Roth a n d Elkayam, 3 43% o f t h e w o m e n w i t h m y o c a r d i a l infarction d u r i n g p r e g n a n c y w e r e f o u n d to have c o r o n a r y atherosclerosis with or without intracoronary thrombus, 21% h a d c o r o n a r y t h r o m b u s only, 16% h a d coron a r y dissection, a n d 29% h a d n o r m a l c o r o n a r i e s . T h e c u m u l a t i v e m a t e r n a l m o r t a l i t y in this series w a s 21%, w i t h t h e r a t e s in t h e p e r i p a r t u m a n d p o s t p a r t u m p e r i o d b e i n g m u c h h i g h e r t h a n t h o s e in t h e anteparturn p e r i o d . C o r o n a r y a r t e r y d i s s e c t i o n a s s o c i a t e d w i t h pregn a n c y o c c u r s m o s t c o m m o n l y d u r i n g t h e t h i r d trim e s t e r o r t h e early p o s t p a r t u m p e r i o d 4 a n d unfortun a t e l y has a dismal p r o g n o s i s . 5 C o r o n a r y a r t e r y diss e c t i o n in t h e p e r i p a r t u m p e r i o d is n o t g e n e r a l l y a s s o c i a t e d w i t h m a t e r n a l h y p e r t e n s i o n o r significant atherosclerosis.5 T h e p a t h o g e n e s i s o f t h i s e n t i t y is u n k n o w n . H o w e v e r , t h e LAD c o r o n a r y a r t e r y is t h e m o s t c o m m o n l y affected vessel. O f f u r t h e r i n t e r e s t is t h e fact t h a t t h e d i s s e c t i o n m o s t often involves t h e p r o x i m a l 2 c m o f t h e LAD. Pathologic e x a m i n a t i o n has r e v e a l e d d e g e n e r a t i v e m o r p h o l o g i c c h a n g e s in t h e a r t e r i a l wall, w i t h a n a c c u m u l a t i o n o f a m o r p h o u s i n t e r c e l l u l a r m a t e r i a l at t h e d i s s e c t i o n site. T h e s e c h a n g e s are b e l i e v e d to b e m o s t likely i n d u c e d b y h o r m o n a l c h a n g e s surrounding t h e p e r i p a r t u m p e r i o d . 6 T h e h e m a t o m a s are usually c o n f m e d to t h e media, w i t h o u t e v i d e n c e o f an intimal tear, l e a d i n g s o m e to believe that t h e h e m o d y n a m i c s t r e s s e s r e l a t e d to p r e g n a n c y , labor, a n d d e l i v e r y m a y also lead to a loss o f structural i n t e g r i t y o f t h e b l o o d vessel wall. T h e diagnosis o f p e r i p a r t u m c o r o n a r y d i s s e c t i o n in m o s t i n s t a n c e s has b e e n e s t a b l i s h e d p o s t m o r t e m . This is t h e first c a s e o f c o r o n a r y a r t e r y d i s s e c t i o n d e t e c t e d b y TEE in a w o m a n in h e r p e r i p a r t u m perio d . J a k o b et al 7 r e p o r t e d a p a t i e n t w h o w a s a d m i t t e d to t h e h o s p i t a l after c o l l a p s e w i t h r e t r o g r a d e amnesia. T h e TEE s h o w e d a d i s s e c t i o n w i t h i n t h e a o r t i c root, which was extending into the ostium and l u m e n o f t h e left m a i n c o r o n a r y artery. TEE-detected c o r o n a r y a r t e r y d i s s e c t i o n has also b e e n r e p o r t e d b y C h e r n g et al8 o n a p a t i e n t h a v i n g s u s t a i n e d a b l u n t c h e s t trauma. T h e TEE s h o w e d a s h o r t intimal flap l o c a t e d in t h e p r o x i m a l LAD. S p o n t a n e o u s c o r o n a r y a r t e r y dissection is a p o t e n tially c a t a s t r o p h i c event that is a rare c o m p l i c a t i o n of pregnancy. In this case,TEE w a s successful n o t only in ruling o u t aortic dissection, b u t also in identifying dissection o f t h e p r o x i m a l LAD as well as assessing global a n d r e g i o n a l left v e n t r i c u l a r function. TEE allows imaging o f the left m a i n and p r o x i m a l LAD in the vast m a j o r i t y o f p a t i e n t s . In t h e p r o p e r clinical setting,
Lerakis, Manoukian, Martin 1133
g
Figure 1 Magnified view of LAD artery (white arrows) showing very thick wall with narrowed lumen. This view was taken at level o f aortic vane with angle of interrogation being 30%.
m e t i c u l o u s attention should b e p a i d to t h e thickness o f the walls of t h e p r o x i m a l LAD, as the unusual thickening and h y p o e c h o i c nature o f t h e wall, in t h e p r o p er clinical setting, strongly l e d to t h e s u s p i c i o n o f a c o r o n a r y a r t e r y dissection. Careful e x a m i n a t i o n a n d m e t i c u l o u s o b s e r v a t i o n o f all cardiac and extracardiac s t r u c t u r e s d u r i n g TEE c a n significantly i m p a c t t h e m a n a g e m e n t o f critically ill patients.
REFERENCES
1. Hoppe UC, Beuckelmann DJ, Bohm M, Erdmann E. A young mother with severe chest pain. Heart 1998;79:205. 2. Morris CD, Hurst JW, Logue RB. Myocardial infarction in young women. Am J Cardiol 1976;38:299-304. 3. Roth A, Elkavam U. Acute myocardial infarction associated with pregnacy. Ann Intern Med 1996;125:751-62. 4. Vicari R, Eybel C, Monson D. Survival following spontaneous coronary artery dissection: surgical repair by extrusion of intramural hematoma. Am Heart J 1986;111:593-4. 5. Engelman DT, Thayer J, Derossi J, Scheinerman ], Brown L. Pregnancy related coronary artery dissection: a case report and collective review. Conn Med 1993;57:135-9. 6. Sage MD, Koelmeyer TD, Smeeton WM. Fatal postpartum coronary artery dissection-a light-and electron-microscope study. Am J Forensic Med Pathol 1986;7:107-11. 7. Jakob M, Ritter M, Rickli H, Jenni R. Transesophageal colour Doppler detection of coronary artery dissection. Lancet 1994;343:1574-5. 8. Cherng W, Bullard MJ, Chang H, Lin F. Diagnosis of coronary dissection following blunt trauma by transesophageal echocardiography. J Trauma Injury Infect Crit Care 1995;39:
772-4.