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Abstrait

Spontaneous distal marginal branch dissection in a young lady during lactation in peripartum with no flow limitation at presentation and evolved in a severe dissection of circumflex, left main and anterior descending artery complicated with cardiogenic shock.

Daniele Forlani, Massimo Di Marco, Alberto D’Alleva, Tommaso Civitarese, Laura Pezzi, Roberta Magnano, Piergiusto Vitulli, Fabio Fulgenzi, Leonardo Paloscia

We talk about a young female 39 years old that was three months postpartum and come to our hospital for chest pain during night lactation of the child. In the emergency room the chest pain was well and we find a normal EKG, Echocardiogram and normal myocardial enzyme at first determination. At 3 hours myocardial enzyme was high so she was recovered in our intensive care unit for acute coronary syndrome non- ST elevation. In the morning was performed a coronary angiography where we found a little hematoma of distal marginal branch without flow limitation, so we decided, according to the AHA and ESC Guideline, for medical conservative therapy. On the third day the patient have again chest pain with big ST elevation on D1, aVL, V3-V6 so we decided to perform another coronary angiography to fix the marginal branch. We bring an EBU 3.5 6 F from left radial and at the first injection we find a complete retrograde dissection from marginal branch till Circumflex and LAD with TIMI FLOW 0-1. We observe a drop of pressure and many polymorphic ventricular extrasystole and an evolution on cardiogenic shock . We fast put gently a guidewire in the LAD, the wire goes in the septal and then was push in the distal portion. We bring a semi compliant balloon 2.0x20 and inflate at 10 atm, and a better flow on LAD was seen so we put faster as possible a stent 3.5x26 mm on left main/LAD. The blood pressure was better and we a few minutes to plan our bail out PTCA. We put a wire on Circumflex and the we start to stent the LAD till the distal portion that appear dissected. We try to inject less contrast as possible because there is a flap with an horrible hematoma in the ostial Left main, so we fix it with another stent in overlapping with the first. At the end we stent al the left system from Left main to the LAD and circumflex till the marginal branch. After optimization there was yet a sign of dissection under the stent in the left main and LAD and circumflex but we decided not to over expansion the stents because of her coronary fragility. This case speaks about spontaneous coronary artery dissection because there is no evidence of any coronary damage. It occurs in young lady in good heal and without risk factor for coronary artery disease in particular in the peripartum period. The presentation was similar to the acute coronary syndrome. According to the AHA and ESC Guideline the therapy was conservative if the dissection/hematoma is no flow limitation with an coronary angiography after a few days to demonstrate the restoration of the vessel. The complete repair of the vessel is mostly observed after 6 months from the acute coronary syndrome