2020 SCAI SHOCK

Title

Spontaneous Coronary Artery Dissection Complicated by Cardiogenic Shock

Introduction

Cardiogenic shock from spontaneous coronary artery dissection (SCAD) is a rare complication for a rare disease. This case demonstrates the use of mechanical support and complex percutaneous coronary intervention (PCI) as a bridge to transplant for the management of cardiogenic shock in the setting of SCAD.

Clinical Case

A 49 year-old female with no significant past medical history presented with acute onset chest pain and ventricular fibrillation cardiac arrest. Electrocardiogram was consistent with ST-elevation myocardial infarction. A cardiac catheterization was performed and she was diagnosed with SCAD involving the left main (LM) coronary artery, extending into the left anterior descending (LAD) artery. She had an Impella CP® percutaneous left ventricular assist device placed for hemodynamic support, but remained in cardiogenic shock, so she was placed on veno-arterial extracorporeal membrane oxygenation (VA-ECMO). She underwent PCI of the LM and LAD coronary arteries, but continued to have refractory cardiogenic shock requiring inotropic support, and thus underwent heart-kidney dual-organ transplantation. Her post-operative course was unremarkable and she was discharged to an acute rehab facility.

Discussion

In SCAD, intervention is warranted for those with involvement of the left main coronary artery and cardiogenic shock. PCI for SCAD is technically challenging. Use of a manifold for contrast injection and the utilization of intravascular ultrasound is helpful. Mechanical support devices and VA-ECMO can stabilize the patient until more definitive therapies are administered. Orthotopic heart transplantation or durable left ventricular assist devices should be considered for refractory heart failure and cardiogenic shock.