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Intra-aortic balloon pumping was immediately started, followed by haemodynamic improvement. A double coronary artery bypass graft was successfully performed the same day (left internal mammary artery to LAD, saphenous vein graft to obtuse marginal branch).
A 39 year old woman was admitted on December 1999 after resuscitation from cardiac arrest, which occurred during Holter monitoring (ST segment elevation followed by ventricular fibrillation was documented). The woman complained of recent onset chest discomfort with syncope. She had no coronary risk factors, no drug abuse, and no significant diseases in her history, although she suffered from migraine (which was being treated with sumatriptan 50 mg/day). On arrival, the patient had pronounced anterolateral ST segment elevation; infusion of nitrates, heparin, and β blockers provided prompt clinical evidence of reperfusion. For this reason, coronary arteriography was delayed.
Four days later, the patient had recurrent chest pain at rest, with unexpected ST segment elevation in inferior leads, and hypotension (80/45 mm Hg). Urgent coronary arteriography was carried out.
Angiographic findings are shown (15° right anterior oblique, 10° cranial view). A long dissection involved the whole left main coronary stem (LM), with contrast dye persisting outside the lumen, and extended both to the left anterior descending artery (LAD) and to the left circumflex artery (LCX). In the LAD, persistence of extraluminal contrast was evident in the proximal segment, while a radiolucent linear streak could be noted in the whole mid portion; in the LCX the dissection involved the proximal segment and ended in a tight stenosis of the true lumen, with impaired anterograde flow.