Primary spontaneous coronary artery dissection complicated by iatrogenous aortic dissection: from David procedure to full arterial coronary
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a Department of Cardiovascular Surgery B (Pr Jegaden), Hpital Pradel, Universite Claude Bernard, INSERM 0226, Bron, France
b Department of Radiology (Pr Douek), Hpital Pradel, Bron, France
Abstract
Introduction: Primary spontaneous coronary artery dissection (PSCAD) is an uncommon cause of acute myocardial infarction that can lead to fatal course especially because of non-standardized management. We report the case of a 37-year-old woman who presented with a PSCAD of the right coronary artery. Patient: A young woman was addressed to our hospital for a PSCAD of the right coronary artery (RCA). During the coronary angiogram, an iatrogenous type II aortic dissection occurred. She was then scheduled for surgery since ascending aortic diameter after the dissection was measured at 52 mm. Method: A David procedure was made to replace the aortic root. Since weaning from cardiopulmonary bypass (CPB) was easy without ischemic signs in the right territory, we didn't systematically graft the RCA. Thirty minutes after the end of the procedure, a cardiogenic shock occurred witnessing a complete thrombosis of the RCA. CPB was restarted and the RCA was grafted on-pump using a right internal thoracic artery (RITA). The left network was examined and also showed to be dissected. Using the LITA, a T-graft was constructed and the left anterior descending and a marginal branch were grafted, rendering the weaning from CPB possible. Result: Postoperative troponin at day 1 was 93 μg/l. Weaning from inotropic drugs and from intra-aortic balloon pump was possible after four days. Extubation was postponed because of a pulmonary infection due to hemophilus influenzae. It was done at day 14. Echographic control showed no residual aortic insufficiency. CT-scan showed a patent RITA-to-RCA graft but an involution of the LITA graft, along with a healing of the left network. Conclusion: PSCAD is a severe condition and its management is unclear. The grafting of the diseased coronaries can be facilitated by an on-pump technique and the use of a coronary shunt to avoid further ischemia.
Key Words: Spontaneous coronary artery dissection; Aortic dissection; David procedure; OPCAB
1. Introduction
Primary spontaneous coronary artery dissection (PSCAD) is an uncommon cause of acute myocardial infarction. It occurs often in young females and concerns in general a single coronary artery. The initial presentation is most likely unstable angina pectoris and must be evocated in the patient without a cardiovascular risk factor [1–4]. The causes of PSCAD remain unknown and the prognosis is very often dark with high risk of death due to the absence of standardized management.
Herein we present the case of a woman with a PSCAD of the right coronary artery (RCA), secondarily complicated by an iatrogenous type A aortic dissection during angiogram. The operative technique and the imaging follow up are discussed.
2. Case report
A 37-year-old woman was admitted in a peripheral hospital for chest pain with dorsal and brachial irradiations. Risk factors for coronary artery disease were hypertension and smoking. She had no personal nor familial Marfan syndrome, connective tissue disease or recent chest trauma. The ECG showed acute inferior myocardial infarction. A trans-thoracic echocardiograph showed an aortic dilatation without aortic valve insufficiency, confirmed by CT-scan. Since Troponin I level was elevated, a thrombolytic treatment was started immediately (in addition to 8 tablets of clopidogrel), without efficacy upon ECG or clinical signs. The patient was then transferred to our institution for coronary angiography. It revealed a dissection of the RCA starting at the proximal segment, and a normal left network. A second injection of radiomarker was immediately associated with an aortic dissection starting from inside the coronary artery and extending towards the brachicephalic trunk (Figs.1 and 2). The procedure was then immediately stopped. The next day, a CT-scan confirmed the aortic dissection with a non-circulating false lumen, without pericardial effusion (Fig. 3). Inside the false lumen we could still see a persistence of the radiomarker. The aortic dissection started from the right coronary artery and extended towards the left main stem, without extension into the left network. The patient was then discussed for surgery but postponed for two more days because of the recent thrombolysis, the clopidogrel treatment, and the absence of residual chest pain.
Surgery was performed via full sternotomy. CPB was started between the right atrium and the aortic arch. After opening the aorta, the examination of the root confirmed the extension in between both coronary arteries. The entry site was not found inside the right coronary artery. A David procedure was performed. The aortic root was dissected from the pulmonary artery, the right ventricle, and the right atrium. Six 2/0 U-stiches were passed below the aortic valve and were used to attach a 26-mm valsalva DacronTM tube (VascutekTM). The aortic cusps were suspended inside the tube and the edges of the aortic sinuses that were previously resected were sutured inside the tube using a 4/0 polypropylene. The coronary ostias were repaired using biologic glue, and reimplanted laterally on the valsalva segment of the tube. After distal anastomosis, and declamping, the patient was weaned from CPB without inotropic support and under continuous transesophageal echography (TEE) monitoring, without ischemic signs in the RCA territory.
Thirty minutes after the end of the procedure, the patient presented with a sudden cardiac shock needing inotropic support. TEE showed biventricular failure. Immediately the patient was reoperated and CPB was restarted for assistance. Progressively, ECG revealed ischemic signs in the RCA territory. The right internal thoracic artery (RITA) was then harvested. RCA was dissected in its second segment and stabilized using an Octopus IVTM device. The RCA was opened, showing a circumferential thrombus of the false lumen. The thrombus was removed using a small FogartyTM catheter. The true lumen was identified and opened and a 2.5-mm shunt was inserted in order to apply the different layers of the dissected coronary. After the RITA anastomosis, TEE showed a progressive improvement in the right ventricular function, but the left ventricle remained globally hypokinetic. An attempt to wean CPB failed despite important inotropic support. The left network was consequently explored, showing a diffuse dissection of the left anterior descending and circumflex arteries. The LITA was then harvested and 5 cm of its distal part cut in order to construct a Y graft. The LAD and a marginal branch were anastomosed using the Octopus IVTM.
Following a systematic insertion of an intra-aortic balloon pump (IABP), the CPB was weaned easily with a low inotropic support. Twenty-four hour troponin level was 93 μmol/l. The postoperative hemodynamic status was rapidly stable allowing the weaning of the IABP on POD 4. Follow up was marked by a pulmonary infection due to hemophilus influenzae needing antibiotic treatment. Extubation was possible on POD 15. A control CT-scan showed a perfect patency of the RITA-to-RCA graft (Figs. 4 and 5) but a hypoplasia of the LITA graft, along with a normal aspect of the left network. Echographic control showed no aortic insufficiency and a LVEF of 59%. Course after 3 months is free from cardiac events.
3. Discussion
Primary spontaneous coronary artery dissection (PSCAD) is a very rare condition. The etiology remains unknown but hypertension, Marfan syndrome, connective tissue disease or immune system disease can be found [5,6]. Sometimes, a recent chest trauma is related [7]. The initial presentation is frequently sudden death, acute coronary syndrome, or congestive heart failure [1,8]. The location of the dissection is usually the proximal portion of a single artery but multiple vessels can be concerned simultaneously [1].
In our case, the coronary angiography showed a right coronary dissection. Unfortunately, the injection of radiomarker was complicated by an aortic dissection. Even if it was clearly risky, the decision to wait two days before surgery was taken to minimize the bleeding risk because of the recent thrombolytic treatment and in the absence of residual chest pain, ECG signs, and heart failure.
The surgical decision is also to be discussed. Iatrogenic aortic dissections can sometimes be treated with conservative therapy. In the present case, we have to face a form of non-circulating aortic wall hematoma. The first CT-scan showed that the aorta was dilated (42 mm). After the occurrence of the dissection, the external diameter was measured at 52 mm. The David procedure was done as a routine technique in aortic dissection. It is our department's politics in aortic dissections in patients before 70 years old. Since the weaning from CPB was easy without electrical or echocardiographic disorders, we decided not to graft systematically the RCA. The secondary cardiogenic shock was probably due to the thrombosis of the false lumen of the RCA and consecutively the flow stop. This condition led the anesthesiologist to perform a flash of inotropic drugs with a subsequent rise of the arterial blood pressure (250 mmHg over 5 to 6 min). This was probably the reason for the secondary dissection of the left network.
In our approach to resolve the coronary problem, two decisions were of importance. The use of an OctopusTM stabilizer avoided additional ischemia for the heart, and the insertion of a coronary shunt in each suture allowed a more reliable grafting technique. In postoperative, the absence of development of the LITA is probably due to the cicatrisation of the left network, shown by the CT-scan images (Fig. 5).
In conclusion, the management of a PSCAD must be quick to avoid as much as possible myocardial ischemia. The beating heart technique with the use of a systematic coronary shunt must be discussed as often as possible. Yet, one should not forget the help of ventricular assist devices in case of failure of the revascularization.
References
Celik SK, Sagcan A, Altintig A, Yuksel M, Akin M, Kultursay H. Primary spontaneous coronary artery dissections in atherosclerotic patients. Report of nine cases with review of the pertinent literature. Eur J Cardiothorac Surg 2001; 20:573–576.
Almeda FQ, Barkatullah S, Kavinsky CJ. Spontaneous coronary artery dissection. Clin Cardiol 2004; 27:377–380.
Sharma AD, Sreeram G, Slaughter TF. Spontaneous coronary artery dissection in a healthy 24-year-old woman. J Cardiothorac Vasc Anesth 2000; 14:312–313.
Eltchaninoff H, Cribier A, Letac B. Peripheral and coronary artery dissections in a young woman. A rare case of type IV Ehlers-Danlos syndrome. Arch Mal Coeur Vaiss 1997; 90:841–844.
Fournier JA, Lopez-Pardo F, Fernandez-Cortacero JA, Sanchez A. Spontaneous coronary artery dissection in mitral stenosis. Eur Heart J 1995; 16:869–871.
Masuda T, Akiyama H, Kurosawa T, Ohwada T. Long-term follow-up of coronary artery dissection due to blunt chest trauma with spontaneous healing in a young woman. Intensive Care Med 1996; 22:450–452.
Ferrari E, Tozzi P, von Segesser LK. Spontaneous coronary artery dissection in a young woman: from emergency coronary artery bypass grafting to heart transplantation. Eur J Cardiothorac Surg 2005; 28:349–351.
Cohen DE, Strimike CL. A case of multiple spontaneous coronary artery dissections. Catheter Cardiovasc Interv 2000; 49:318–320.(Fadi Farhat, Thomas Sassa)
b Department of Radiology (Pr Douek), Hpital Pradel, Bron, France
Abstract
Introduction: Primary spontaneous coronary artery dissection (PSCAD) is an uncommon cause of acute myocardial infarction that can lead to fatal course especially because of non-standardized management. We report the case of a 37-year-old woman who presented with a PSCAD of the right coronary artery. Patient: A young woman was addressed to our hospital for a PSCAD of the right coronary artery (RCA). During the coronary angiogram, an iatrogenous type II aortic dissection occurred. She was then scheduled for surgery since ascending aortic diameter after the dissection was measured at 52 mm. Method: A David procedure was made to replace the aortic root. Since weaning from cardiopulmonary bypass (CPB) was easy without ischemic signs in the right territory, we didn't systematically graft the RCA. Thirty minutes after the end of the procedure, a cardiogenic shock occurred witnessing a complete thrombosis of the RCA. CPB was restarted and the RCA was grafted on-pump using a right internal thoracic artery (RITA). The left network was examined and also showed to be dissected. Using the LITA, a T-graft was constructed and the left anterior descending and a marginal branch were grafted, rendering the weaning from CPB possible. Result: Postoperative troponin at day 1 was 93 μg/l. Weaning from inotropic drugs and from intra-aortic balloon pump was possible after four days. Extubation was postponed because of a pulmonary infection due to hemophilus influenzae. It was done at day 14. Echographic control showed no residual aortic insufficiency. CT-scan showed a patent RITA-to-RCA graft but an involution of the LITA graft, along with a healing of the left network. Conclusion: PSCAD is a severe condition and its management is unclear. The grafting of the diseased coronaries can be facilitated by an on-pump technique and the use of a coronary shunt to avoid further ischemia.
Key Words: Spontaneous coronary artery dissection; Aortic dissection; David procedure; OPCAB
1. Introduction
Primary spontaneous coronary artery dissection (PSCAD) is an uncommon cause of acute myocardial infarction. It occurs often in young females and concerns in general a single coronary artery. The initial presentation is most likely unstable angina pectoris and must be evocated in the patient without a cardiovascular risk factor [1–4]. The causes of PSCAD remain unknown and the prognosis is very often dark with high risk of death due to the absence of standardized management.
Herein we present the case of a woman with a PSCAD of the right coronary artery (RCA), secondarily complicated by an iatrogenous type A aortic dissection during angiogram. The operative technique and the imaging follow up are discussed.
2. Case report
A 37-year-old woman was admitted in a peripheral hospital for chest pain with dorsal and brachial irradiations. Risk factors for coronary artery disease were hypertension and smoking. She had no personal nor familial Marfan syndrome, connective tissue disease or recent chest trauma. The ECG showed acute inferior myocardial infarction. A trans-thoracic echocardiograph showed an aortic dilatation without aortic valve insufficiency, confirmed by CT-scan. Since Troponin I level was elevated, a thrombolytic treatment was started immediately (in addition to 8 tablets of clopidogrel), without efficacy upon ECG or clinical signs. The patient was then transferred to our institution for coronary angiography. It revealed a dissection of the RCA starting at the proximal segment, and a normal left network. A second injection of radiomarker was immediately associated with an aortic dissection starting from inside the coronary artery and extending towards the brachicephalic trunk (Figs.1 and 2). The procedure was then immediately stopped. The next day, a CT-scan confirmed the aortic dissection with a non-circulating false lumen, without pericardial effusion (Fig. 3). Inside the false lumen we could still see a persistence of the radiomarker. The aortic dissection started from the right coronary artery and extended towards the left main stem, without extension into the left network. The patient was then discussed for surgery but postponed for two more days because of the recent thrombolysis, the clopidogrel treatment, and the absence of residual chest pain.
Surgery was performed via full sternotomy. CPB was started between the right atrium and the aortic arch. After opening the aorta, the examination of the root confirmed the extension in between both coronary arteries. The entry site was not found inside the right coronary artery. A David procedure was performed. The aortic root was dissected from the pulmonary artery, the right ventricle, and the right atrium. Six 2/0 U-stiches were passed below the aortic valve and were used to attach a 26-mm valsalva DacronTM tube (VascutekTM). The aortic cusps were suspended inside the tube and the edges of the aortic sinuses that were previously resected were sutured inside the tube using a 4/0 polypropylene. The coronary ostias were repaired using biologic glue, and reimplanted laterally on the valsalva segment of the tube. After distal anastomosis, and declamping, the patient was weaned from CPB without inotropic support and under continuous transesophageal echography (TEE) monitoring, without ischemic signs in the RCA territory.
Thirty minutes after the end of the procedure, the patient presented with a sudden cardiac shock needing inotropic support. TEE showed biventricular failure. Immediately the patient was reoperated and CPB was restarted for assistance. Progressively, ECG revealed ischemic signs in the RCA territory. The right internal thoracic artery (RITA) was then harvested. RCA was dissected in its second segment and stabilized using an Octopus IVTM device. The RCA was opened, showing a circumferential thrombus of the false lumen. The thrombus was removed using a small FogartyTM catheter. The true lumen was identified and opened and a 2.5-mm shunt was inserted in order to apply the different layers of the dissected coronary. After the RITA anastomosis, TEE showed a progressive improvement in the right ventricular function, but the left ventricle remained globally hypokinetic. An attempt to wean CPB failed despite important inotropic support. The left network was consequently explored, showing a diffuse dissection of the left anterior descending and circumflex arteries. The LITA was then harvested and 5 cm of its distal part cut in order to construct a Y graft. The LAD and a marginal branch were anastomosed using the Octopus IVTM.
Following a systematic insertion of an intra-aortic balloon pump (IABP), the CPB was weaned easily with a low inotropic support. Twenty-four hour troponin level was 93 μmol/l. The postoperative hemodynamic status was rapidly stable allowing the weaning of the IABP on POD 4. Follow up was marked by a pulmonary infection due to hemophilus influenzae needing antibiotic treatment. Extubation was possible on POD 15. A control CT-scan showed a perfect patency of the RITA-to-RCA graft (Figs. 4 and 5) but a hypoplasia of the LITA graft, along with a normal aspect of the left network. Echographic control showed no aortic insufficiency and a LVEF of 59%. Course after 3 months is free from cardiac events.
3. Discussion
Primary spontaneous coronary artery dissection (PSCAD) is a very rare condition. The etiology remains unknown but hypertension, Marfan syndrome, connective tissue disease or immune system disease can be found [5,6]. Sometimes, a recent chest trauma is related [7]. The initial presentation is frequently sudden death, acute coronary syndrome, or congestive heart failure [1,8]. The location of the dissection is usually the proximal portion of a single artery but multiple vessels can be concerned simultaneously [1].
In our case, the coronary angiography showed a right coronary dissection. Unfortunately, the injection of radiomarker was complicated by an aortic dissection. Even if it was clearly risky, the decision to wait two days before surgery was taken to minimize the bleeding risk because of the recent thrombolytic treatment and in the absence of residual chest pain, ECG signs, and heart failure.
The surgical decision is also to be discussed. Iatrogenic aortic dissections can sometimes be treated with conservative therapy. In the present case, we have to face a form of non-circulating aortic wall hematoma. The first CT-scan showed that the aorta was dilated (42 mm). After the occurrence of the dissection, the external diameter was measured at 52 mm. The David procedure was done as a routine technique in aortic dissection. It is our department's politics in aortic dissections in patients before 70 years old. Since the weaning from CPB was easy without electrical or echocardiographic disorders, we decided not to graft systematically the RCA. The secondary cardiogenic shock was probably due to the thrombosis of the false lumen of the RCA and consecutively the flow stop. This condition led the anesthesiologist to perform a flash of inotropic drugs with a subsequent rise of the arterial blood pressure (250 mmHg over 5 to 6 min). This was probably the reason for the secondary dissection of the left network.
In our approach to resolve the coronary problem, two decisions were of importance. The use of an OctopusTM stabilizer avoided additional ischemia for the heart, and the insertion of a coronary shunt in each suture allowed a more reliable grafting technique. In postoperative, the absence of development of the LITA is probably due to the cicatrisation of the left network, shown by the CT-scan images (Fig. 5).
In conclusion, the management of a PSCAD must be quick to avoid as much as possible myocardial ischemia. The beating heart technique with the use of a systematic coronary shunt must be discussed as often as possible. Yet, one should not forget the help of ventricular assist devices in case of failure of the revascularization.
References
Celik SK, Sagcan A, Altintig A, Yuksel M, Akin M, Kultursay H. Primary spontaneous coronary artery dissections in atherosclerotic patients. Report of nine cases with review of the pertinent literature. Eur J Cardiothorac Surg 2001; 20:573–576.
Almeda FQ, Barkatullah S, Kavinsky CJ. Spontaneous coronary artery dissection. Clin Cardiol 2004; 27:377–380.
Sharma AD, Sreeram G, Slaughter TF. Spontaneous coronary artery dissection in a healthy 24-year-old woman. J Cardiothorac Vasc Anesth 2000; 14:312–313.
Eltchaninoff H, Cribier A, Letac B. Peripheral and coronary artery dissections in a young woman. A rare case of type IV Ehlers-Danlos syndrome. Arch Mal Coeur Vaiss 1997; 90:841–844.
Fournier JA, Lopez-Pardo F, Fernandez-Cortacero JA, Sanchez A. Spontaneous coronary artery dissection in mitral stenosis. Eur Heart J 1995; 16:869–871.
Masuda T, Akiyama H, Kurosawa T, Ohwada T. Long-term follow-up of coronary artery dissection due to blunt chest trauma with spontaneous healing in a young woman. Intensive Care Med 1996; 22:450–452.
Ferrari E, Tozzi P, von Segesser LK. Spontaneous coronary artery dissection in a young woman: from emergency coronary artery bypass grafting to heart transplantation. Eur J Cardiothorac Surg 2005; 28:349–351.
Cohen DE, Strimike CL. A case of multiple spontaneous coronary artery dissections. Catheter Cardiovasc Interv 2000; 49:318–320.(Fadi Farhat, Thomas Sassa)