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A 51-year-old postmenopausal woman presented at her local hospital with severe chest pain of sudden onset that radiated to the left arm and neck, shortness of breath, palpitation, and diaphoresis. She had no risk factors for coronary artery disease. Electrocardiographic (ECG) results were consistent with a diagnosis of acute inferior myocardial infarction. Reteplase was administered for thrombolysis. Glyceryl trinitrate and heparin infusion were started, and the patient was transferred to our hospital for further management. Upon arrival, she was free of angina. Approximately 4 hours after admission, severe angina recurred, and she underwent urgent coronary angiography. Extensive dissection involving the left anterior descending and left circumflex coronary arteries was seen (Fig. 1). The right coronary artery was normal. The left ventricular systolic function was normal. Due to ongoing angina and ischemic changes in the inferior and lateral ECG leads, an intra-aortic balloon pump was inserted, and urgent coronary artery bypass surgery was performed. Standard cardiopulmonary bypass and cardioplegia were used. During surgery, an extensive dissection was found, with a “vessel inside the vessel” appearance (Figs. 2A and and2B).2B). There were no atherosclerotic plaques or any signs of atherosclerosis at the sites of the anastomoses or anywhere else in the coronary arteries. The left internal thoracic artery was grafted to the left anterior descending coronary artery, and greater saphenous vein grafts were used to bypass the diagonal and obtuse marginal arteries. Two layers of the dissected arteries were approximated and incorporated into a suture line with use of 7-0 Prolene suture (Ethicon Inc., a Johnson & Johnson company; Somerville, NJ) (Fig. 2). The patient made an uneventful recovery.
Spontaneous coronary artery dissection is rarely encountered, and approximately 80% of patients with this condition are young women.1 The most common clinical presentation (in 60%–80% of instances) is sudden cardiac death.1 Approximately 70% of these patients have dissection in a single coronary artery only; spontaneous left main dissection has been reported in 15% of the cases.1 Spontaneous dissection of multiple coronary vessels without left main coronary artery involvement, as in our patient, is very rare. The precise cause of spontaneous coronary artery dissection is unknown. The increased incidence of this condition in the peri- and postpartum periods is possibly related to a hormonal influence that weakens the architecture of the coronary artery wall. Increased hemodynamic stress related to pregnancy appears to further predispose the weakened arterial wall to dissection.2
Because the diagnosis of spontaneous coronary artery dissection can be difficult due to various clinical manifestations, a high index of suspicion is required. Upon angiography, a radiolucent line between the 2 lumina of an artery3 and contrast retention in the false lumen are diagnostic.
Address for reprints: Igor E. Konstantinov, MD, PhD, Professor of Surgery, University of Western Australia; and Department of Cardiothoracic Surgery, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Perth, WA 6009, Australia