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Severe upper abdominal pain in a 43-year-old woman
  1. Elad Asher,
  2. Alexander Kogan,
  3. Amit Segev
  1. Leviev Heart Center, Sheba Medical Center Tel Hashomer, Tel-Aviv University, Tel Hashomer, Israel
  1. Correspondence to Dr Elad Asher, Heart Institute, Sheba Medical Center Tel Hashomer 5265601, Israel; el.asher{at}gmail.com

Abstract

Clinical introduction A 43-year-old healthy woman was transferred to our hospital due to severe upper abdominal pain during lunch. On arrival to the hospital she lost consciousness, had no pulse and no blood pressure; hence, the cardiopulmonary resuscitation was initiated and the patient was intubated. Echocardiography performed during the resuscitation revealed ejection fraction of 5% with global hypokinesia. The patient was put on extracorporeal membrane oxygenation and was transferred to the catheterisation laboratory. The initial angiography and the post percutaneous coronary intervention (PCI) images are shown in figure 1.

Figure 1

Images of (A) initial angiography and (B) post percutaneous coronary intervention.

Question What is the diagnosis?

  1. Aortic dissection

  2. Emboli to the left main coronary artery

  3. Plaque rupture causing acute ST segment elevation myocardial infarction

  4. Spasm

  5. Spontaneous coronary artery dissection

Question

  • spontaneous coronary artery dissection
  • percutaneous coronary artery intervention
  • acute coronary syndrome

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Answer: E

Angiography was positive for left main coronary (LM) artery dissection. PCI to the LM artery, left anterior descending (LAD) arteries and left circumflex (LCX) artery was initiated, and a drug-eluting stent was deployed from the LM artery to the LAD artery with provisional approach to the LCX artery. The dissection flap could still be seeing behind the stent struts after the stent was deployed, although high-pressure post stenting balloon inflation was performed. The angiography and PCI are available in the online supplementary files 1–7). Atherosclerosis was not present in all the coronary arteries and in conjugation with the patient’s age and history, plaque rupture (answer C) was highly unlikely. Spasm (answer D) was not supposed to cause dissection. After crossing the LM with the guide wire, no thrombus/mass or distal embolisation was observed (answer B). The aorta was intact (answer A). The dissection was found on the first injection when the patient was already on extracorporeal membrane oxygenation and an echocardiography exam showed stunning of the entire heart; hence, it is likely that the dissection was causing the situation and was not a consequence of the procedure technique during angioplasty. The acute setting together with the patient’s gender, age, dissection, tortuosity of the arteries and the lacking of atherosclerosis have led to the diagnosis of spontaneous coronary artery dissection (SCAD). During her course of admission, her ejection fraction was improved to 25%. In women <50 years old presenting with acute coronary syndrome, the prevalence of SCAD was reported to be as high as 8.7%.1 Unfortunately, SCAD can result in significant morbidities such as myocardial ischaemia and infarction, ventricular arrhythmias and sudden cardiac death.2

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References

Footnotes

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.