Multivessel Post-Partum Spontaneous Coronary Artery Dissection (SCAD) complicated by Cardiogenic Shock
Moemen Eltelbany, MD, Inova Heart and Vascular Institute, Falls Church, VA
Moemen Eltelbany, MD1, Mariyam Sheidu, MD1, Andrew H. Nguyen, DO2, Raghav Gattani, MBBS2 and Shashank Sinha, MD, MSc3, (1)Inova Heart and Vascular Institute, Falls Church, VA, (2)Inova Heart and Vascular Institute, Fairfax, VA, (3)Inova Health System, Falls Church, VA
Keywords: Cardiogenic Shock
Title: Multivessel Post-Partum Spontaneous Coronary Artery Dissection (SCAD) complicated by Cardiogenic Shock Introduction: Spontaneous coronary artery dissection (SCAD) is an infrequent cause of acute coronary syndrome (ACS). Various cohorts report cardiogenic shock (CS) as a complication in 2-3% of patients.1 Data supporting use of mechanical circulatory support (MCS) in SCAD complicated by CS is limited, advocating for individualized decision-making in this patient population.2 Clinical Case: A 35-year-old female with history of postpartum SCAD of the right coronary artery (RCA) treated with drug eluting stenting 5 years prior, presented with acute substernal chest pain and anterior ST elevations on ECG 1 week following her fourth delivery. Follow-on coronary angiography demonstrated a type I dissection of the mid-to-distal segments of the left anterior descending coronary artery (LAD) with TIMI 2 flow (Figure 1). The patient was hemodynamically stable and chest pain resolved so no intervention was performed. She was discharged home on beta-blocker, statin, and dual antiplatelet therapy (DAPT).3 One week later she re-presented to a spoke Hospital Emergency Department with recurrent acute substernal chest pain and widespread ST depressions in lateral and precordial leads and ST elevation in lead aVR on ECG. Repeat urgent coronary angiography revealed a new type I dissection involving the proximal left circumflex coronary artery (LCX) (Figure 2) and extension of the recent LAD dissection into the left main coronary artery (LM) with TIMI 1-2 flow (Figure 2) with patent stent in RCA (Figure 3). She very rapidly developed multi-pressor-refractory hypotension and cardiogenic shock (SCAI Stage D) prompting referral to a local hub Shock Center. On arrival her EF was 10% by bedside Echocardiography in the Cardiac ICU. In the setting of persistent hemodynamic instability and cardio-pulmonary failure she underwent emergent intubation and veno-arterial extracorporeal membrane oxygenation (VA-ECMO) cannulation. After 72 hours and hemodynamic stabilization she was successfully decannulated. GDMT was initiated and DAPT continued. Echocardiography was repeated prior to discharge demonstrating improvement of LVEF to 40%. She was discharged home with outpatient follow up with Advanced Heart Failure and surveillance CT coronary angiography. Discussion According to recent case series, 2-3% of SCAD patients may develop cardiogenic shock.1 Current scientific statements favor a conservative approach for management of SCAD patients.3 Percutaneous or surgical revascularization may be considered in the setting of ongoing refractory ischemia, hemodynamic instability, left main or multivessel lesions involving proximal vessel segments subtending large areas of myocardium.3,4 The utility of MCS in the management of CS for SCAD patients is unknown due to limited data overall and particularly in the SCAD and post-partum SCAD patient population. Potential risks of MCS include peripheral vascular or aortic injury – particularly in the setting of underlying vasculopathy (which has an higher incidence in SCAD relative to other ACS etiologies) – and must be weighed against potential benefits.5 Some recent non-randomized data support the early use of MCS in such patients with reported higher survival rates.2