Postpartum dissection of the left main coronary artery

Abstract

Summary: Peripartum coronary artery dissection is rare, but it is an increasingly recognized risk to women of childbearing age. Literature reviews reveal that about 80% of the population with spontaneous coronary artery dissections (SCAD) are female, and approximately 25-33% of cases occurred while the woman was pregnant or in the peripartum phase. Most cases have presented within 2 weeks of delivery. The left anterior descending is the most commonly affected vessel. The etiology is poorly understood, but many reports suggest that SCAD occurs as a result of protease release secondary to an eosinophilic vasculitis resulting in vessel lysis. Many investigators have examined the correlation between peripartum SCAD and estrogen levels; however, case studies have shown conflicting results regarding estrogen levels as the putative causative factor. Optimal treatment remains controversial. Presently, stenting appears to be best employed in the patients who have singlevessel dissection not involving the left main coronary artery (LMCA). Surgical revascularization via coronary artery bypass graft remains the optimal therapy in patients whose dissection involves the LMCA, in patients with concurrent multivessel dissection, and in patients with disease refractory to medical management. It is important to consider coronary artery dissection in the differential of any young woman who presents with signs or symptoms consistent with acute coronary syndrome, particularly if she is peripartum. Furthermore, once suspected, it is imperative that a definitive diagnostic study, that is, coronary angiography, be completed prior to the initiation of treatment whenever possible.

Postpartum Spontaneous Coronary Artery Dissection: How to Manage?

“…In case of multivessel involvement and LMCA dissection, taking the percentage of ischemic myocardium at risk into consideration, surgery seems to be the best alternative (10)(11)(12) . In surgery, incorporation of true and false lumen is essential.…”

Dissection of the left main coronary artery after blunt thoracic trauma: Case report and literature review

“…Other causes of dissection unrelated to trauma include spontaneous lesions and iatrogenic injuries from coronary angiography. Spontaneous dissections have a 4:1 predilection for women with 25-33% occurring during pregnancy or the peripartum period [ 14 ]. Spontaneous lesions are associated with three conditions: 1) pre-existing coronary artery disease; 2) hormonal factors, such as pregnancy or oral contraceptive use, as stated above [ 14 - 16 ]; and 3) patients with tissue fragility disorders (e.g., Marfan's or Ehler-Danlos syndromes) [ 17 ].…”

“…Spontaneous dissections have a 4:1 predilection for women with 25-33% occurring during pregnancy or the peripartum period [ 14 ]. Spontaneous lesions are associated with three conditions: 1) pre-existing coronary artery disease; 2) hormonal factors, such as pregnancy or oral contraceptive use, as stated above [ 14 - 16 ]; and 3) patients with tissue fragility disorders (e.g., Marfan's or Ehler-Danlos syndromes) [ 17 ]. Mortality with spontaneous dissection can be up to 70%, based on post-mortem studies after sudden cardiac death [ 17 ].…”

Critical Insights Into the Management of Postpartum Left Main Spontaneous Coronary Artery Dissection: Current Strategies and Future Directions

“…Achieving and maintaining hemodynamic stability is a primary concern in these critical scenarios. This involves swiftly implementing a series of carefully orchestrated medical interventions and close monitoring to mitigate the potentially life-threatening consequences of the condition [ 24 ].…”

“…CABG provides a stable conduit for blood flow, avoiding the challenges associated with stent placement in fragile arteries. The success of CABG depends on the complexity of the dissection, the surgical technique employed, and the patient's overall health [ 23 , 24 ].…”