Recurrent myocardial infarction caused by peripartum left main spontaneous coronary artery dissection, extending to the left anterior descending artery and left circumflex artery

摘要

Spontaneous coronary artery dissection(SCAD) is an important cause of myocardialinfarction (MI) in otherwise healthy young andmiddle-aged patients without cardiovascularrisk factors. Herein, is reported a multiparous(5 pregnancies, 5 deliveries) 45-year-old womanwithout cardiovascular risk factors who presentedto the emergency room, 3 months after her lastdelivery, for oppressive retrosternal chest painirradiating in the left arm. Electrocardiogramdemonstrated negative T waves from V2–V6, I, IIand avL. High sensitivity troponins were elevatedat 293 ng/L ? 1345 ng/L. Coronary angiogramdemonstrated left main SCAD (type 2) with extension to the distal left anterior descending artery(LAD) and the proximal circumflex artery (LCx).The right coronary artery demonstrated no signsof SCAD (Fig. 1A–C). The patient did not presenta trigger factor for SCAD. Echocardiographyshowed moderate left ventricular dysfunction(ejection fraction 45–50%), with apical akinesia and infero-septal hypokinesia. In the presence of conserved antegrade flow, conservativetreatment was performed, and the patient wasstarted on dual antiplatelet therapy by meansof acetylsalicylic acid 100 mg/d and clopidogrel75 mg/d. Heart failure therapy with angiotensin--converting enzyme inhibitors and beta-blockerswas initiated. Forty-eight hours after the initialangiogram the patient presented recurrent retrosternal chest pain. Electrocardiogram showednegative T waves from V2–V6, as well as in leadsII, III and avF and troponins were elevated at 477 g? 3775 ng/L, confirming recurrent MI. Repeatcoronary angiogram demonstrated the previouslyseen spontaneous coronary artery dissections(type 2) with progression of the dissection of thecircumflex artery to the distal segment of the vessel, associated with occlusion of the distal LCx(Fig. 1D–F). In the absence of hemodynamic instability, it was decided to treat the LCx dissectionconservatively. Clinical evolution was favourable at6 month follow-up. On echocardiography persistence of apical akinesia was visualized, witha slight left ventricular dysfunction (ejectionfraction 50%). Control angiogram demonstratedcomplete healing of the left main, left circumflex artery and left anterior descending artery(Fig. 1G–I). Peripartum associated SCAD represent a high-risk subset of patients, is associatedwith high-risk clinical presentation and increasedcardiovascular morbidity.