SPONTANEOUS ANTERIOR DESCENDING CORONARY ARTERY DISSECTION TREATED BY PERCUTANEOUS CORONARY INTERVENTION: A CASE REPORT

Introduction Spontaneous coronary artery dissection results in a haemorrhagic separation of the media with the creation of a false lumen. The dissection may heal spontaneously but more frequently it occludes the real lumen causing myocardial ischemia, myocardial infarction, sudden cardiac death or heart failure. Sudden cardiac death is the outcome of the majority of these cases; prognosis is generally poor and about 70% of reported cases have been identified post-mortem. Although the pathogenesis, aetiology, prevalence and prognosis remain unclear, spontaneous coronary artery dissection is commonly observed in four broad patient groups: patients in the peri-partum period (one third of cases); patients with coronary atherosclerosis (about 30% of cases); patients with underlying condition other than pregnancy and atherosclerosis (in the minority of cases, association with connective tissue diseases such as Marfan’s syndrome and Ehlers-Danlos type IV, with systemic lupus erythematosus, with certain condition such as vigorous exercise or cocaine abuse); idiopathic cases, when an underlying condition cannot be identified. There also appears to be distinct gender differences in arterial involvement: in women, most commonly the left artery is involved, whereas in men, it is the right. Since it was first described by Pretty in 1931, only a few hundred cases have been reported in the literature. Case Report A 56-year-old post-menopausal woman came to the emergency department with a 2-hour history of severe chest pain. She had no conventional risk factors for ischemic heart disease and she was not on any medication. An initial electrocardiogram (ECG) revealed nonspecific abnormalities; troponin T levels were normal and an echocardiogram did not show any regional wall motion abnormalities or left ventricular dysfunction. The patient, who reported a slight improvement in symptoms, was hospitalized for observation; 8 hours after admission the patient experienced a new onset of severe chest pain. An ECG revealed ST elevation in leads V1-V3, T-wave inversion in leads V4-V6 and a prolonged QT-interval (Fig. 1). Troponin T levels rose to 0.32 ng/mL (normal level <0.03 ng/mL). Despite medical therapy she continued to experience chest pain with dynamic ECG changes; echocardiogram showed apical hypokinesis without left ventricular global dysfunction. 24 hours after admission, cardiac catheterization was performed and revealed a longitudinal dissection flap in the middle and distal segment of the left anterior descending (LAD) coronary artery (Fig. 2); no atherosclerotic plaques were observed on the other coronary arteries. In view of the mono-vessel nature of the disease, the patient’s ongoing symptoms and the clear visualization of the dissection line in the LAD, the decision was made SPONTANEOUS ANTERIOR DESCENDING CORONARY ARTERY DISSECTION TREATED BY PERCUTANEOUS CORONARY INTERVENTION: A CASE REPORT