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Kanda T, Tawarahara K, Matsukura G, Matsunari M, Takabayashi R, Tamura J, Ozeki M, Ukigai H. The Diagnosis of Spontaneous Coronary Artery Dissection by Optical Coherence Tomography. Intern Med 2018; 57:523-526. [PMID: 29269638 PMCID: PMC5849548 DOI: 10.2169/internalmedicine.8862-17] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Spontaneous coronary artery dissection (SCAD) is rare, but it frequently presents as acute myocardial infarction. It is frequently fatal and most cases are diagnosed at autopsy. We herein present the case of a 65-year-old woman with ST-elevation and myocardial infarction due to SCAD. Optical coherence tomography (OCT) helped us to confirm the diagnosis. The information on the intravascular morphology provided by OCT imaging is much more detailed in comparison to that provided by coronary angiography (CAG) and intravascular ultrasound (IVUS).
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Affiliation(s)
- Takahiro Kanda
- Department of Internal Medicine, Division of Cardiology, Hamamatsu Red Cross Hospital, Japan
| | - Kei Tawarahara
- Department of Internal Medicine, Division of Cardiology, Hamamatsu Red Cross Hospital, Japan
| | - Gaku Matsukura
- Department of Internal Medicine, Division of Cardiology, Hamamatsu Red Cross Hospital, Japan
| | - Masayoshi Matsunari
- Department of Internal Medicine, Division of Cardiology, Hamamatsu Red Cross Hospital, Japan
| | - Rumi Takabayashi
- Department of Internal Medicine, Division of Cardiology, Hamamatsu Red Cross Hospital, Japan
| | - Jun Tamura
- Department of Internal Medicine, Division of Cardiology, Hamamatsu Red Cross Hospital, Japan
| | - Mariko Ozeki
- Department of Internal Medicine, Division of Cardiology, Hamamatsu Red Cross Hospital, Japan
| | - Hiroshi Ukigai
- Department of Internal Medicine, Division of Cardiology, Hamamatsu Red Cross Hospital, Japan
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Rose E, Gedela M, Miller N, Carpenter PL. Pregnancy-Related Spontaneous Coronary Artery Dissection: A Case Series and Literature Review. J Emerg Med 2017; 52:867-874. [PMID: 28396082 DOI: 10.1016/j.jemermed.2017.02.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 02/04/2017] [Accepted: 02/25/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Cardiac emergencies during pregnancy are rare but have significant associated morbidity and mortality when they do occur. The emergency physician must not only be aware of potentially life-threatening conditions in the pregnant woman, but also know the emergent management and treatment of these conditions to avoid worsening of the underlying condition. Pregnancy-related spontaneous coronary artery dissection has been described in the cardiology literature, but is not well-known in emergency medicine literature. CASE SERIES We present a case series of six previously healthy women ages 27 to 39 years who presented 1 to 75 days after delivery with spontaneous coronary artery dissection. The left main coronary was involved in 5 of 6 cases. One patient died, 5 survived. Two survivors maintained significant long-term disability. The patient that died had the diagnosis made on autopsy, the others were diagnosed with coronary angiography. Two patients were treated with stents, 2 with coronary artery bypass surgery, and 2 with medical management. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergent coronary catheterization is indicated if this diagnosis is suspected. However, emergency care teams must also understand how and why management including coronary artery catheterization can exacerbate the underlying condition. The role of coronary artery computed tomography remains unknown, although it exposes the fetus to significant radiation if the woman is still pregnant at presentation. Medical management is indicated with diffuse or distal disease as pregnancy-related coronary artery dissections often resolve with time. Localized discrete lesions may be stented. Coronary artery bypass graft surgery may be considered if the left main artery is involved or there are multiple proximal lesions. Cardiac transplantation is indicated rarely.
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Affiliation(s)
- Emily Rose
- Department of Emergency Medicine, Keck School of Medicine of the University of Southern California, LAC+USC Medical Center, Los Angeles, California
| | - Maheedhar Gedela
- Department of Internal Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota
| | - Nathan Miller
- Department of Internal Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota
| | - Paul L Carpenter
- Department of Cardiology, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota
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Abstract
Spontaneous coronary artery dissection (SCAD) remains an infrequent, elusive, and challenging clinical entity of unknown etiology eight decades after its initial description. Our understanding of the pathophysiology of SCAD, initially limited to information from early pathological studies, case reports, and very short series, has been enriched recently by relatively large contemporary series of patients studied prospectively. The typical presentation involves a young woman without coronary risk factors suffering an acute coronary syndrome but, actually, most patients are middle-aged and have coronary risk factors. A high number of conditions have been related to SCAD, but fibromuscular dysplasia has shown a major intriguing association with potential pathophysiological implications. SCAD may present (a) with an intimal tear and the classic angiographic 'flap' leading to the appearance of two lumens (true and false), or (b) without an intimal rupture, as an intramural hematoma. An increased clinical awareness together with new diagnostic tools have led to a major surge in the diagnosis of SCAD. High-resolution intracoronary techniques provide unique diagnostic insights into the underlying pathophysiology and facilitate identification of the disease in patients misdiagnosed previously. After the initial acute ischemic insult, most patients stabilize and have a benign clinical course and eventually experience spontaneous healing of the vessel wall during follow-up. However, recurrences may still occur in up to 10-20% of cases. Accordingly, a conservative medical management (watchful waiting strategy) has been recommended as the initial approach. Revascularization remains particularly challenging and may be associated with suboptimal results, acute complications, and poor long-term outcome. Nevertheless, in patients with ongoing or refractory ischemia and adequate anatomy, revascularization should be attempted. Some novel and attractive coronary interventions have been proposed in this uniquely challenging anatomic scenario. This review aims to present a comprehensive and contemporary update on this elusive and intriguing clinical entity.
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Bernelli C, Sirbu V, Guagliumi G. Percutaneous Coronary Intervention Planning and Optimization with Optical Coherence Tomography. Interv Cardiol Clin 2015; 4:251-284. [PMID: 28581944 DOI: 10.1016/j.iccl.2015.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Coronary angiography confirms or excludes coronary artery disease, assesses lesions severity, and helps to decide percutaneous coronary interventions (PCI). Coronary angiography has clear limitations. Intravascular imaging guides PCI. Frequency domain optical coherence tomography (OCT) gained attention for accurate planning and guidance of complex PCI. High-speed OCT image acquisition enables prompt vessel assessment in stable and unstable patients. The high-resolution images provide precise tissue characterization and a reliable quantitative assessment of the coronary pathology. Immediately after stent implantation, OCT allows accurate evaluation of stent expansion and symmetry. Real-time angio-OCT co-registration integrates OCT into the PCI workflow for accurate decision making.
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Affiliation(s)
- Chiara Bernelli
- Interventional Cardiology Unit, Azienda Ospedaliera Papa Giovanni XXIII, Piazza OMS 1, Bergamo, 24127, Italy
| | - Vasile Sirbu
- Interventional Cardiology Unit, Azienda Ospedaliera Papa Giovanni XXIII, Piazza OMS 1, Bergamo, 24127, Italy
| | - Giulio Guagliumi
- Interventional Cardiology Unit, Azienda Ospedaliera Papa Giovanni XXIII, Piazza OMS 1, Bergamo, 24127, Italy.
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Franco C, Eng L, Saw J. Optical Coherence Tomography in the Diagnosis and Management of Spontaneous Coronary Artery Dissection. Interv Cardiol Clin 2015; 4:309-320. [PMID: 28581947 DOI: 10.1016/j.iccl.2015.02.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Spontaneous coronary artery dissection (SCAD) is an infrequent condition that has been underdiagnosed and misdiagnosed. The use of intracoronary imaging with intravascular ultrasound or optical coherence tomography enables the accurate diagnosis of this challenging condition. Diagnostic and management algorithms have been proposed to improve the diagnosis and therapeutic stratification of SCAD. Optical coherence tomography has superior spatial resolution than intravascular ultrasound, and is instrumental in the diagnosis of SCAD cases where angiographic findings are ambiguous for confirming SCAD. Understanding the role and appropriate and careful use of this technology is expected to improve the diagnosis of SCAD, and also improve outcomes with percutaneous coronary intervention, when clinically indicated.
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Affiliation(s)
- Christopher Franco
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, 2775 Laurel Street, Level 9, Vancouver, BC V5Z1M9, Canada
| | - Lim Eng
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, 2775 Laurel Street, Level 9, Vancouver, BC V5Z1M9, Canada
| | - Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, 2775 Laurel Street, Level 9, Vancouver, BC V5Z1M9, Canada.
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D'Ovidio C, Sablone S, Carnevale A. Spontaneous coronary artery dissection: case report and literature review. J Forensic Sci 2015; 60:801-6. [PMID: 25678077 DOI: 10.1111/1556-4029.12722] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Revised: 02/26/2014] [Accepted: 05/22/2014] [Indexed: 11/28/2022]
Abstract
Spontaneous coronary artery dissection (SCAD) is a rare cause of acute myocardial infarction and sudden cardiac death. It occurs most commonly in otherwise healthy women during pregnancy or the postpartum period. The true incidence of SCAD is underestimated, as most cases are diagnosed at autopsy. The pathophysiology of SCAD is still not fully understood, and its management can be challenging. This report describes a 35-year-old pregnant female who presented with an acute antero-lateral ST elevation secondary to spontaneous dissection of the left anterior descending artery and the circumflex artery. The diagnosis was established by coronary artery angiography. However, the patient died following cardiac tamponade. The examination of this case represented a starting point for the reviewing of the diagnosis, clinical course, and management of SCAD, and for the placing of this in context with the existing literature. This study highlights the importance of prompt diagnosis and subsequent lifesaving treatment.
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Affiliation(s)
- Cristian D'Ovidio
- Section of Legal Medicine, Department of Medicine and Aging Sciences, 'G. d'Annunzio' University of Chieti-Pescara, Via dei Vestini, 31, 66100, Chieti, Italy
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Spontaneous coronary artery dissection. Int J Cardiol 2014; 175:8-20. [DOI: 10.1016/j.ijcard.2014.04.178] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Revised: 02/19/2014] [Accepted: 04/17/2014] [Indexed: 02/03/2023]
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Alfonso F, Bastante T, Rivero F, Cuesta J, Benedicto A, Saw J, Gulati R. Spontaneous Coronary Artery Dissection. Circ J 2014; 78:2099-110. [DOI: 10.1253/circj.cj-14-0773] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | | | | | - Javier Cuesta
- Cardiac Department, Hospital Universitario de La Princesa
| | | | - Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, University of British Columbia
| | - Rajiv Gulati
- Division of Cardiovascular Diseases, Mayo Clinic
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Nishiguchi T, Tanaka A, Ozaki Y, Taruya A, Fukuda S, Taguchi H, Iwaguro T, Ueno S, Okumoto Y, Akasaka T. Prevalence of spontaneous coronary artery dissection in patients with acute coronary syndrome. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2013; 5:263-70. [PMID: 24585938 DOI: 10.1177/2048872613504310] [Citation(s) in RCA: 207] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Accepted: 07/29/2013] [Indexed: 12/15/2022]
Abstract
AIMS Spontaneous coronary artery dissection (SCAD) found typically in young females without classical coronary risk factors is thought to be a very rare cause of acute coronary syndrome (ACS). The prevalence of SCAD in ACS subjects has been unclear, probably due to the nature of coronary angiography. The aim of this study was to use optical coherence tomography (OCT) to investigate the prevalence of SCAD in ACS. METHODS AND RESULTS This study consisted of 326 patients with ACS (with or without ST-segment elevation) who underwent OCT to explore the entire culprit artery. According to OCT findings, patients were divided into a SCAD, a plaque rupture (PR), and a non-SCAD/non-PR group. OCT revealed 13 (4.0%) SCADs and 160 (49.1%) plaque ruptures in ACS subjects. The percentage of females versus males was greater in the SCAD group (SCAD: 53.8% vs. PR: 20.0% vs. non-SCAD/non-PR: 23.5%, p=0.02) while no difference was observed in age (SCAD: 67.3±13.3 vs. PR: 66.5±11.1 vs. non-SCAD/non-PR: 67.0±10.5, p=0.90). The prevalence of dyslipidemia (SCAD: 30.8% vs. PR: 63.8% vs. non-SCAD/non-PR: 67.5%, p=0.03) and current smoking (SCAD: 7.7% vs. PR: 57.9% vs. non-SCAD/non-PR: 59.7%, p<0.01) were significantly lower in the SCAD group. CONCLUSIONS SCAD is not a rare cause for ACS, especially in females without classical coronary risk factors.
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Affiliation(s)
| | - Atsushi Tanaka
- Department of Cardiovascular Medicine, Social Insurance Kinan Hospital, Tanabe, Japan
| | - Yuichi Ozaki
- Department of Cardiovascular Medicine, Wakayama Medical University, Japan
| | - Akira Taruya
- Department of Cardiovascular Medicine, Social Insurance Kinan Hospital, Tanabe, Japan
| | - Shota Fukuda
- Department of Cardiovascular Medicine, Osaka Ekisaikai Hospital, Japan
| | - Haruyuki Taguchi
- Department of Cardiovascular Medicine, Osaka Ekisaikai Hospital, Japan
| | - Tetsuya Iwaguro
- Department of Cardiovascular Medicine, Social Insurance Kinan Hospital, Tanabe, Japan
| | - Satoshi Ueno
- Department of Cardiovascular Medicine, Social Insurance Kinan Hospital, Tanabe, Japan
| | - Yasushi Okumoto
- Department of Cardiovascular Medicine, Social Insurance Kinan Hospital, Tanabe, Japan
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University, Japan
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Alfonso F, Paulo M, Gonzalo N, Dutary J, Jimenez-Quevedo P, Lennie V, Escaned J, Bañuelos C, Hernandez R, Macaya C. Diagnosis of spontaneous coronary artery dissection by optical coherence tomography. J Am Coll Cardiol 2012; 59:1073-9. [PMID: 22421300 DOI: 10.1016/j.jacc.2011.08.082] [Citation(s) in RCA: 281] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Revised: 08/03/2011] [Accepted: 08/26/2011] [Indexed: 01/25/2023]
Abstract
OBJECTIVES This study sought to assess the diagnostic value of optical coherence tomography (OCT) in patients with suspected spontaneous coronary artery dissection (SCAD). BACKGROUND SCAD is a rare but challenging clinical entity. METHODS Following a prospective protocol, OCT was performed in 17 consecutive patients with a clinical and angiographic suspicion of SCD from a total of 5,002 patients undergoing coronary angiography. A conservative management strategy was followed. RESULTS OCT ruled out the diagnosis of SCAD in 6 patients with coronary artery disease (atherosclerotic plaques and/or intracoronary thrombus). In 11 patients (age 48 ± 9 years, 9 female), OCT confirmed the presence of SCAD. A double-lumen or intramural hematoma image was visualized in all cases. However, only 3 patients presented an intimal "flap" on angiography. OCT readily identified the intimal rupture site (n = 7), the thickness (348 ± 84 μm) and length (31 ± 9 mm) of the intimomedial membrane, the area of the true (1.1 ± 0.5 mm(2)) and false lumen (5.9 ± 2.1 mm(2)), the associated intramural hematoma (n = 9), and thrombi in the true or false lumens (n = 11). Most of these findings were angiographically silent. After stenting (n = 4), OCT disclosed adequate stent coverage, expansion, and apposition, but also residual intramural hematoma at the stented site (abluminal) and at the distal vessel. CONCLUSIONS OCT provides unique insights in patients with SCAD that allow an early diagnosis and adequate management. Most of these findings are undetectable by angiography.
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Affiliation(s)
- Fernando Alfonso
- Interventional Cardiology Unit, Cardiovascular Institute, IdISSC, Complutense University, Clínico San Carlos, University Hospital, Madrid, Spain.
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Nakagawa M, Shite J, Shinke T, Otake H, Okada K, Okita Y, Hirata KI. Ability of Optical Coherence Tomography to Visualize the Entry Port of Spontaneous Coronary Artery Dissection. Circ J 2011; 75:2505-7. [DOI: 10.1253/circj.cj-11-0329] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Masayuki Nakagawa
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Junya Shite
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Toshiro Shinke
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Hiromasa Otake
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Kenji Okada
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine
| | - Yutaka Okita
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine
| | - Ken-ichi Hirata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
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