Contemporary management of pregnancy-related coronary artery dissection: A single-centre experience and literature review

Abstract

Spontaneous coronary artery dissection (SCAD) is an infrequent event that is most commonly associated with pregnant women or those in the postpartum period. Because of its rarity, the literature describing this condition is confined to sporadic case reports, with few reporting long-term follow-up, and no clear consensus exists on the optimal treatment strategy for these patients. The present article reports a single-centre experience with SCAD, highlighting the issues surrounding its management with a brief description of five cases of pregnancy-associated coronary dissection. The treatment used in these cases ranged from a conservative medical approach to surgical and percutaneous intervention, with one patient proceeding to transplantation. Four of the cases have long-term angiographic follow-up.In addition, a comprehensive review of all previously published cases is presented, and temporal trends in the management strategy are highlighted. Possible pathophysiological mechanisms pertaining to this condition, and the complex diagnostic and therapeutic issues involved, which may affect both patient and fetus, are discussed. Finally, an optimal approach to patients with SCAD, informed by our experience and literature review, is described.

Keywords: Myocardial infarction; Peripartum; Pregnancy; Spontaneous coronary dissection.

Figure 1)

Case 1. Angiography (right anterior oblique view) of the left anterior descending artery. A Initial angiogram demonstrating mid to distal vessel narrowing, no dissection plane identified. B Following percutaneous coronary intervention with bare metal stents, there is an excellent mid-vessel appearance with residual narrowing of the distal vessel. Thrombolysis in myocardial infarction 3 flow was demonstrated distally. C Second admission with chest pain, extension of dissection clearly evident in distal left anterior descending artery. The patient underwent further stenting with drug-eluting stents. D Repeat angiography demonstrated patent left anterior descending stents, with minor distal disease (unstented)

Figure 2)

Case 2. Angiography (left anterior oblique view) of the right coronary artery. A Initial angiogram showing the dissection plane in the right coronary artery (arrows). B Appearance after stenting with bare metal stents

Figure 3)

Case 5. Angiography of the left main stem. A Initial angiogram (right anterior oblique caudal view) showing left main stem dissection (arrow). B The following day the dissection extended into the left anterior descending and circumflex arteries (arrows). C Angiogram five years after coronary artery bypass graft surgery. Dissection plane with false lumen seen in the right coronary artery (arrows) (left anterior oblique cranial view). The timing of this event is unknown