Spontaneous Coronary Artery Dissection: Good Long-term Outcome with IVUS-Guided Diagnosis and Management Italo Porto Interventional Cardiology Unit Università Cattolica del Sacro Cuore Rome, Italy Fondi, 28 Giugno 2008

Italo Porto, MD, PhD DISCLOSURES I have no real or apparent conflicts of interest to report.

Background Intravascular ultrasound (IVUS) may help defininig the etiology of Acute Coronary Syndrome (ACS) when no obvius culprit is found at angiography Spontaneous coronary artery dissection (SCAD) is a rare and potentially fatal cause of ACS SCAD pathogenesis and therapeutic approach are yet undefined, with percutaneous treatment, surgery, and medical therapy advocated by different authors We here describe a case of SCAD in a young woman who was treated with medical management, due to the absence of IVUS high risk features. 3

Clinical presentation Female, 46 years Cardiovascular risk factor: family history of cardiovascular disease No previous cardiovascular events. Recent severe stressful event 8:00 a.m. sudden onset of chest pain defined as typical angina Ecocardiography: apical akinesia with moderate reduction of ejection fraction Cardiac Troponin T level in the first sample: 0.08 ng/ml 4

Coronary angiography After intra-coronary ergonovine (32 ) 60% stenosis of proximal LAD diffuse LAD vasoconstriction, severe on LAD ostium 5

IVUS atheroma lumen haematoma Intramural haematoma (external to and compressing EEL) starting from mid-LAD up to LAD ostium, with lumen compromise. No side branches or LCX compromise Presence of non obstructive atheroma. MLA=5.2 mm2 at LAD ostium. 6

…..at 48 hours Medical therapy with angiotensin-converting enzyme inhibitors, beta-blocker, statin, aspirin, and clopidogrel haematoma atheroma lumen 7

…..at 3 months atheroma lumen Fondi, 28 Giugno 2008 8

Speckle Tracking Echo Left: Speckle strain analysis in apical 4 chamber view 2 days after chest pain, shows an important reduction of the transmural strain in apical segments (AS, AL) and in mid inferoseptal segment. Right: Speckle strain analysis in apical 4 chamber view 3 months after chest pain, shows the recovery of the transmural strain in the involved segments

Discussion IVUS imaging can be considered extremely useful (manadatory?) in the diagnosis and treatment of SCAD IVUS allows SCAD diagnosis (often unclear from angio pictures), and precise evaluation of: SCAD extension Side branch or ostial compromise Presence of coexisting atheroma (protective?) Early serial IVUS evaluation may also give insights on haematoma internal pressure (is it growing?) In absence of high risk features and tendency to grow, medical treatment (with IVUS follow-up) can be reasonable Fondi, 28 Giugno 2008 10

Conclusions SCAD is a rare cause of myocardial infarction that typically, occurs in healthy postpartum women The site of dissection usually involves the proximal coronary arteries Optimal treatment (drugs, surgery or stenting) has not been clearly established and may depend on the clinical scenario and on the location and extent of dissection IVUS-guided treatment resulted in symptoms resolution and in almost complete disappearance of intramural haematoma at 3 months Fondi, 28 Giugno 2008 11