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Asian Cardiovasc Thorac Ann 2000;8:54-55
© 2000 Asia Publishing EXchange Pte Ltd

CASE STUDY

Spontaneous Dissection of Left Main Coronary Artery: Surgical Management

Lokeswara Rao Sajja, MCh, Afroz Farooqi, MCh, Ramesh Babu Yarlagadda, MD1,, Mastan Saheb Shaik, MD1,, Ramesh Babu Pothineni, DM2,

Division of Cardiothoracic Surgery
1 Division of Cardiac Anaesthesiology
2 Division of Cardiology
Citi Cardiac Research Centre
Vijayawada, Andhra Pradesh, India
For reprint information contact: Lokeswara Rao Sajja, MCh Tel: 91 866 47 0881 Fax: 91 866 47 3554, Division of Cardiothoracic Surgery, Citi Cardiac Research Centre, Ring Road, Near ITI College, Vijayawada, Andhra Pradesh 520008, India.

   Abstract
TOP
 Abstract
Introduction
 Case Report
 Discussion
 References
 
Spontaneous dissection of a coronary artery is a rare cause of obstructive coronary artery disease and sudden death. We report a case of spontaneous dissection of the left main coronary artery, which manifested as ischemic heart disease and was successfully treated by emergency myocardial revascularization. Prompt diagnosis and surgical revascularization are crucial for survival.


   Introduction
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 Abstract
 Introduction
Case Report
 Discussion
 References
 
Spontaneous coronary artery dissection is a rare cause of ischemic heart disease and sudden death. Dissection involving the left main coronary artery is very rare and fewer than 25 cases have been reported.1 Only 6 patients who survived surgical intervention have been reported so far.2–4 This condition occurs predominantly in young healthy women in the 3rd trimester of pregnancy or in the early postpartum period and it has also been reported in the elderly. The involved vessels in order of frequency are the left anterior descending (LAD), right coronary, circumflex, and left main coronary artery.1 The incidence of spontaneous coronary artery dissection is under-estimated as a cause of sudden death.5


   Case Report
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 Abstract
 Introduction
 Case Report
Discussion
 References
 
A 57-year-old man who was diabetic and hypertensive with angina on exertion (Canadian Cardiovascular Society angina class II to III) of 10 days duration, presented with acute onset of severe angina at rest, associated with sweating and vomiting. His electrocardiogram showed acute inferior and posterior wall myocardial infarction (MI) and ischemic changes in the anterior wall. Cardiac enzymes were elevated significantly (serum creatinine kinase 1500 U•L–1, creatinine kinase-MB 80 U•L–1) at the time of admission to a district hospital. He was given thrombolytic therapy within 3 hours of the onset of chest pain, with 1.5 million units of streptokinase administered intravenously. During thrombolytic therapy, he developed recurrent episodes of ventricular fibrillation and he was converted to sinus rhythm by external defibrillation. He was stabilized for the first 2 days on intravenous infusion of nitroglycerin 2.5 µg•kg–1•min–1, heparin sulphate 5000 units 6 hourly, and oral aspirin. The angiotensin-converting enzyme inhibitor enalapril maleate (2.5 mg twice daily) and oral nitrates were added on the 3rd day. In spite of this treatment, he continued to have post-MI unstable angina. On the 11th day post-MI, he was referred to our institute for further evaluation and management. Echo-cardiography showed a mildly dilated left ventricle with an ejection fraction of 0.45 and regional wall motion abnormality in the inferior and anterior walls of the left ventricle. Coronary arteriography showed 50% to 60% stenosis of the proximal left main coronary artery and dissection in the distal segment (Figure 1Go). The LAD and the left circumflex artery and its branches were normal. The right coronary artery showed 60% stenosis in its mid segment.



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  		Figure 1. Coronary angiogram in right anterior oblique view, demonstrating dissection of the distal left main coronary artery (thick arrow) and stenosis of the proximal left main coronary artery (thin arrow).

 
Emergency triple coronary artery bypass grafting was performed with cardiopulmonary bypass, moderate hypothermia (34°C), and antegrade and retrograde blood cardioplegia. The left internal mammary artery was used as a graft to the LAD and reversed saphenous vein grafts were used for the first obtuse marginal and posterolateral branches. The diameter of both the LAD and obtuse marginal was 2 mm and these vessels were healthy at the site of the arteriotomy. The patient was weaned off cardiopulmonary bypass without need of inotropic support or intraaortic balloon counterpulsation. The cardio-pulmonary bypass time was 67 minutes and the ischemic time was 34 minutes. He had an uneventful postoperative recovery with relief of angina and was discharged from the hospital on the 8th postoperative day. Echocardio-graphy at discharge showed persistence of a mild regional wall motion abnormality of the inferior wall and the ejection fraction was 0.5. He remained well, with good exercise tolerance at the 3-month follow-up; the ejection fraction improved to 0.6.


   Discussion
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 Abstract
 Introduction
 Case Report
 Discussion
References
 
The etiology of spontaneous dissection of coronary arteries is not clear. DeMaio and colleagues1 identified 3 separate groups of patients: those with atherosclerotic coronary artery disease; those presenting in the postpartum period; and those without identifiable predisposing factors. Patients with left main coronary artery dissection may present with acute MI, sudden death, or MI with cardiogenic shock.3 Spontaneous dissection may be most catastrophic when the left main coronary artery is involved. Coronary artery dissection may or may not be associated with risk factors for atherosclerotic coronary artery disease.2 Postmortem findings in both men and women often reveal inflammatory infiltrates rich in eosinophils in the adventitia, suggesting that arterial wall damage may be due to release of lytic substances from these cells.6

Coronary artery bypass grafting is the treatment of choice for spontaneous dissection of the left main coronary artery.2,4,7,8 Emergency coronary angiography should be considered in patients, especially those who are young and without risk factors, presenting with acute ischemic syndromes that fail to respond to medical therapy. Early diagnosis is imperative for survival. Emergency myo-cardial revascularization is mandatory and coexisting coronary artery disease must be addressed concomitantly to minimize the chance of further dissection. The internal mammary artery is an ideal conduit for revascularization of the LAD even in these critically ill patients, to achieve good long-term palliation.


   References
TOP
 Abstract
 Introduction
 Case Report
 Discussion
 References
 

  1. DeMaio SJ, Kinsella SH, Silverman ME. Clinical course and long-term prognosis of spontaneous coronary artery dissection. Am J Cardiol 1989;64:471–4.[Medline]

  2. Thayer JO, Healy RW, Maggs PR. Spontaneous coronary artery dissection. Ann Thorac Surg 1987;44:97–102.[Abstract]

  3. Keon WJ, Koshal A, Boyd WD, Loranee L, Farrell E, Walley VM. Survival after spontaneous primary left main coronary artery dissection — acute surgical intervention with Jarvik 7-70 artificial heart. J Cardiovasc Surg 1989;30:786–9.[Medline]

  4. Boyd WD, Walley VM, Keon WJ. Surgical treatment of spontaneous left main coronary artery dissection. Ann Thorac Surg 1988;46:483.

  5. Atay Y, Yagdi T, Turkoglu C, Altintig A, Buket S. Spon-taneous dissection of left main coronary artery: a case report and review of literature. J Card Surg 1996;11: 371–5.[Medline]

  6. Siegel RJ, Koponen MI. Spontaneous coronary artery dissection causing sudden death; mechanical arterial failure or primary vasculitis? Arch Pathol Lab Med 1994;118: 196–8.[Medline]

  7. Alvarez J, Deal CW. Spontaneous dissection of left main coronary artery: a case report and review of literature. Aust NZ J Med 1991;21:891–2.[Medline]

  8. Thistlethwaite PA, Tarazi RY, Giordano FJ, Jamieson SW. Surgical management of spontaneous left main coronary artery dissection. Ann Thorac Surg 1998;66:258–60.[Abstract/Free Full Text]





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