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Spontaneous coronary artery dissection in a young woman: from V-A-ECMO to heart transplant
Session:
Prémio Melhor Caso Clínico
Speaker:
Mariana Sousa Paiva
Congress:
CPC 2023
Topic:
P. Other
Theme:
37. Miscellanea
Subtheme:
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Session Type:
Sessão de Prémios
FP Number:
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Authors:
Mariana Sousa Paiva; Daniel A. Gomes; Catarina Brízido; Rita Bello; Sérgio Maltês; Paulo Oliveira; Christopher Strong; António Tralhão; Marta Pereira Marques; Carlos Aguiar; Miguel Mendes; José Pedro Neves
Abstract
<p><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><strong>Background:</strong></span></span></p> <p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif">Spontaneous coronary artery dissection (SCAD) is an uncommon cause of acute myocardial infarction that can lead to refractory cardiogenic shock (CS), requiring advanced heart failure therapies, such as mechanical circulatory support (MCS) and orthotopic heart transplant (OHT). </span></span></p> <p style="text-align:justify"> </p> <p><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><strong>Case Summary:</strong></span></span></p> <p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif">A previously healthy non-pregnant 41-year-old woman was admitted for a non-ST segment elevation acute coronary syndrome at a non-PCI peripheral hospital and initially treated with dual anti-platelet therapy. After a few hours, recurrent angina and dynamic EKG changes ensued, so fibrinolysis was performed, and she was transferred to a PCI-capable center to receive early invasive coronary angiography. The angiogram revealed type 2 spontaneous dissection of the left main, proximal left anterior descending, and proximal circumflex coronary arteries. A difficult, burdensome PCI was attempted, with 2 stents implanted on the proximal LAD and LM. Despite IVUS confirming adequate guidewire positioning and showing the intramural hematoma, vessel manipulation resulted in progression of the dissection and loss of the distal flow (figure 1-B, C and D). The operators tried to treat the Cx lesion, but the guidewire was always positioned at the false lumen.</span></span></p> <p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif">Consequently, the patient progressed into refractory cardiogenic shock secondary to severe left ventricular systolic dysfunction and was referred to our center for MCS - V-A ECMO. On further investigation, no obvious vascular disease predisposition was found; on the other hand, urine test was positive for amphetamins and cannabinoids. Over the following days, there was no significant recovery of the ventricular function, and she was listed for a heart transplant. During the period of ECMO support, recurrent bleeding from the ECMO cannulas' access site required a total of 13 red blood cell and 2 platelet transfusions. Within 10 days from admission, a donor came up. The pre-surgery crossmatch showed a positive complement-dependent cytotoxicity result for B and T cells, but a negative crossmatch result with the flow cytometry method. The team decided to go through with the surgery, preceded by a session of therapeutic plasma exchange, and an aggressive scheme of immunosuppression with close follow-up for signs of rejection. Postoperative recovery was uneventful, and she was discharged after the first 2 routine endomyocardial biopsies revealed no signs of acute rejection.</span></span></p> <p> </p> <p><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><strong>Discussion</strong>:</span></span></p> <p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif">SCAD is a rare condition mainly affecting young to middle-aged females with predisposing vascular conditions, presenting with myocardial infarction after certain triggers. In severe cases, SCAD can lead to extensive myocardial infarction and irreversible ventricular dysfunction, requiring OHT. MCS can serve as a bridge to transplant in patients with cardiogenic shock.</span></span></p>
Slides
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