Spontaneous primary dissecting coronary artery aneurysm. Report of two cases

Spontaneous dissections of coronary arteries and acute coronary syndromes: rationale and design of the DISCOVERY, a multicenter prospective registry with a case-control group

BACKGROUND

Spontaneous coronary artery dissection (SCAD) is an unusual cause of acute myocardial ischemia that in almost 50% of cases is followed by sudden death. The increasing frequency of SCAD diagnosis may reflect the widespread use of coronary angiography and percutaneous coronary interventions in acute coronary syndromes (ACS). The incidence of SCAD is estimated between 0.1 and 0.28% of all ACS or sudden deaths evaluated by angiography or by anatomical examination, respectively. Most published data available so far deal with single case reports and probably the real incidence of this disease is underestimated. Some predisposing conditions to SCAD are well known and include Marfan syndrome, pregnancy and peripartum state, drug abuse and some anatomical abnormalities of the coronary arteries like aneurysms and severe kinking. The most appropriate therapeutic approach to SCAD is still controversial and decision making is often based on the clinical presentation, extent of dissection and amount of ischemic myocardium.

OBJECTIVES AND METHODS

The purpose of this multicenter prospective registry, named DISCOVERY (DISsection of COronary arteries: Veneto and Emilia RegistrY), with a case-control group is to try to assess the role of SCAD in the pathogenesis of ACS. The primary endpoint is the occurrence of major adverse cardiovascular events related to the therapeutic strategy in the acute phase and in the mid-term follow-up. The secondary endpoints are the estimation of the prevalence of SCAD in the pathogenesis of ACS, the association or disassociation of SCAD with presumptive predisposing factors, the appreciation of the timing and extent of multivessel involvement when present, the occurrence of vascular and ocular comorbidities (i.e. carotid dissection and ocular lens abnormalities), the evaluation of the immediate success and the mid-term outcome of percutaneous coronary interventions and the definition of the role of intravascular ultrasound in diagnosis and treatment of SCAD. The enrollment of approximately 50 patients with SCAD is planned. A planned control group of patients of comparable age, sex and clinical presentation will allow us to identify potential peculiar or specific aspects of SCAD in any phase of the disease.

CONCLUSION

The DISCOVERY multicenter registry, with a case-control group, is the first large prospective study aimed at assessing the role of SCAD in the pathogenesis of ACS and at identifying the role of different therapeutic strategies in this unusual, multifaceted and probably underestimated pathologic condition.

Spontaneous coronary artery dissection involving the left main stem: assessment by intravascular ultrasound

This case report describes the devastating consequences of spontaneous coronary dissection in a 36 year old female patient who otherwise had a normal coronary arteriogram. Intravascular ultrasound showed coronary artery dissection and intramural haematoma at the left main stem coronary artery. Acute coronary syndrome developed and subsequently surgical revascularisation was performed successfully.

Spontaneous dissecting aneurysm of the coronary artery. A rare cause of myocardial infarction and sudden death

Spontaneous dissecting aneurysm of the coronary artery (SDACA) not associated with aortic aneurysm or trauma is a very rare cause of myocardial ischemia. It has a higher prevalence in otherwise healthy women, especially in the peri- and postpartum period. In 80-90% of cases the diagnosis of SDACA is confirmed at autopsy, as the majority of patients present with acute myocardial infarction or sudden death. We describe the case of a 47-year-old Caucasian woman who died suddenly without any previous sign of cardiac disease. She had no clinical signs of Marfan's syndrome or arterial hypertension, she used no oral contraceptives and she was not in the peri- or postpartum period. At autopsy we found a recent dissecting aneurysm of the right coronary artery. Histology showed a hematoma between the media and adventitia of the coronary artery, flattening and occluding the lumen. Acute myocardial infarction was present in the posterior wall of the left cardiac ventricle. SDACA is an unpredictable condition and prompt diagnosis and life-saving procedures--either surgical or conservative--are rarely successful. We report a very rare disease documented in only 108 cases according to the English-language literature accessible to us.

Spontaneous coronary artery dissection: report of two cases and a 50-year review of the literature

Spontaneous coronary artery dissection (SCAD) is a rare condition that can cause acute myocardial infarction and sudden death. This entity occurs predominantly in women. Although several mechanisms have been postulated, no single etiology completely explains the pathogenesis of SCAD. Patients who survive SCAD have been treated with various modalities. Prompt diagnosis and early institution of appropriate treatment are usually associated with successful outcome. We report two cases of SCAD successfully identified and treated with coronary stenting as well as a comprehensive review of cases of SCAD published since 1952.

Spontaneous dissection of three major coronary arteries subsequent to cystic medial necrosis

This case report describes the devastating consequences of spontaneous coronary dissection in a 36-year-old female patient. Surgical revascularization was attempted, but diffuse myocardial infarction developed. The patient was bridged to heart transplantation but died secondary to multiple organ failure. To our knowledge, this is the only reported case of spontaneous dissection of the three main coronary arteries due to severe cystic medial necrosis.

Spontaneous double vessel coronary artery dissection. A case report and surgical management

Spontaneous coronary artery dissection is an uncommon clinical entity, its presentation and management similar to atherosclerotic coronary artery disease. We report on a young adult male who presented with myocardial infarction due to simultaneous dissection of left anterior descending and right coronary artery. He was treated with bilateral interal mammary artery grafts.

Spontaneous dissection of the left main coronary artery: a case report and review of the literature

Primary spontaneous coronary artery dissection is an unusual occurrence. There have been less than 150 cases reported in world literature. This process frequently occurs in relatively young women, particularly in the peripartum or early postpartum period. This article reports the clinical course of one patient with primary spontaneous left main coronary artery dissection who was treated with coronary artery bypass grafting. To our knowledge, it is the second case to be treated with the use of left internal mammary artery.

Spontaneous coronary dissection resulting in acute myocardial infarction: successful treatment with primary angioplasty

Spontaneous coronary dissection is an unusual cause of acute myocardial infarction for which the optimal therapy has not been established. We report the case of a 63-year-old man with acute lateral wall myocardial infarction resulting from spontaneous dissection of the major diagonal branch of the left anterior descending artery in whom acute and long-term patency was restored by primary PTCA.

Spontaneous coronary artery dissection: a neglected cause of acute myocardial ischaemia and sudden death

Spontaneous coronary artery dissection is a rare cause of acute myocardial ischaemia. Eight consecutive fatal cases which occurred in women aged 34-54 years (mean 43) are described. The dissection involved the left anterior descending coronary artery in four, the left main trunk in two, the right coronary artery in one, and both left anterior descending and circumflex arteries in one. The clinical presentation was sudden death in six cases, and acute myocardial infarction in two. Diagnosis was made at necropsy in every case but one, in which coronary dissection was diagnosed during life by selective coronary angiography. The only ascertained risk factor was hypertension in one patient; none of the women was in the puerperium, and Marfan syndrome was excluded in all. Histology showed a haematoma between the coronary tunica media and adventitia, that flattened and occluded the lumen; a coronary intimal tear was detected in only two cases. Unusual histological findings were cystic medial necrosis in one case, eosinophilic inflammatory infiltrates in four, and angiomatosis of the tunica adventitia in one. Patients dying of spontaneous coronary dissection are usually middle aged women, with no coronary atherosclerosis and apparently no risk factors. Spontaneous coronary artery dissection is unpredictable, and sudden death is the usual mode of clinical presentation. Prompt diagnosis and life saving treatment is far from being achieved.

Case report: spontaneous coronary artery dissection

Spontaneous coronary artery dissection is a rare cause of ischaemic heart disease occurring most commonly in young women. It is frequently fatal. Our case is unusual in that a very long dissection flap was diagnosed by coronary angiography in a male patient who presented with only minor symptoms. We discuss the pathogenesis of spontaneous dissection and the prognosis for this group of patients.

Spontaneous primary dissection of the coronary artery

A 41 year old woman died suddenly and unexpectedly as a result of a spontaneous primary dissection of a coronary artery. This rare condition occurs typically in pre-menopausal women often in the peripartum period and hormonal changes have been among several suggested aetiological factors. In this case an association with auto-immune thyroiditis is described for the first time and the importance of extensive examination of the coronary arteries at autopsy is emphasised as the lesion was confined to a small focus near the apex of the heart.

Coronary dissection following chest trauma with systemic emboli

Coronary artery dissection is a rare entity which occurs following blunt chest trauma, during coronary angiography and coronary bypass surgery, and spontaneously in the peripartum period. We report a young man who presented with recurrent systemic emboli following an asymptomatic anterior wall myocardial infarction associated with dissection of the LAD and mural thrombus three years earlier after sustaining blunt chest trauma.

Spontaneous coronary artery dissection

Spontaneous coronary artery dissection is a rare event that occurs most commonly in young, otherwise healthy women. Approximately 85 cases have been reported in the world literature. Dissection of the left main coronary artery is even less common; only 18 cases have been reported. This review discusses the incidence, presentation, pathogenesis, and management of spontaneous coronary artery dissection. The case of another patient with left main coronary artery dissection is described; to our knowledge, it is the first to be successfully treated by internal mammary artery bypass grafting.

Isolated fibromuscular dysplasia of the coronary arteries with spontaneous dissection and myocardial infarction

Fibromuscular dysplasia (FMD) is a segmental, nonatherosclerotic vascular disease of unknown etiology. Both the renal and extrarenal arterial FMD may have focally deficient or absent muscular media, and spontaneous dissection is a serious complication of this arterial wall abnormality. Although FMD may be found in virtually any small and medium-sized arteries, to our knowledge, FMD of the coronary arteries previously has not been documented convincingly in the literature. This article describes one such unusual occurrence of FMD in the coronary arteries with spontaneous dissection and myocardial infarction.

Left coronary artery dissection: an unusual presentation

Primary dissecting aneurysm of the left main stem coronary artery is a rare cause of coronary arterial occlusion that usually presents as sudden death or myocardial infarction in a young woman. A 32 year old woman with no signs of cardiac disease who died as the result of a right cerebral infarction was found to have coronary dissection and myocardial infarction at necropsy.

[Isolated spontaneous coronary artery dissection. A report on the differential diagnosis of coronary heart disease]

A complete review of the literature on the disease entity isolated spontaneous coronary artery dissection (72 ascertained cases with our own three) is given. The emphasis is placed on differential diagnosis of coronary heart disease, particularly in young patients without typical atherosclerotic risk factors. Isolated spontaneous coronary artery dissection is defined as a spontaneously dissecting hematoma limited to one or more coronary arteries. Women are involved considerably more frequently than men (84% of cases). Mean age at onset of the disease is 41 years (range: 21-70 years). The main site of involvement is the left coronary artery (79% of cases). In one-third of the female patients there is a temporal relationship to pregnancy (peripartum coronary artery dissection). Three types can be differentiated by coronary arteriography. Less than one-third of the patients survive the first 24 h after acute onset of symptoms; attempts at emergency reperfusion of the ischemic myocardium by aortocoronary bypass surgery or thrombolytic therapy have not been successful.