Spontaneous coronary artery dissection presenting as acute myocardial infarction

Spontaneous coronary artery dissection is a rare entity being increasingly diagnosed as a cause of acute myocardial infarction, especially in cases of low cardiac risk female patients. This is one such case report of a black female patient, who suffered an acute anterior wall myocardial infarction due to an idiopathic spontaneous coronary artery dissection of the left anterior descending artery. She was treated with a thrombolytic agent in the acute phase, uneventfully. An urgent coronary angiogram demonstrated an intimal tear with a dissection of the left anterior descending artery. She survived the acute event and her subsequent hospital course was uncomplicated. Hence she was treated medically for her ischemic event and left ventricular systolic dysfunction with a favorable outcome. This case is yet another report of a survivor treated with a thrombolytic agent for the acute myocardial infarction due to spontaneous coronary artery dissection.     

Spontaneous coronary artery dissection associated with cocaine use: a case report and brief review.

Isolated, spontaneous dissection of the coronary arteries in the absence of trauma is an unusual but well-documented occurrence. Fewer than 50 cases have been reported in males in the English language literature, and only one case, nonfatal, was associated with cocaine use. We present the second overall and the first fatal case of cocaine-associated spontaneous coronary artery dissection and a brief review of the literature on coronary dissection and the cardiovascular effects of cocaine use. The mechanism of cocaine's toxicity on the heart and vasculature is complex, multifactorial, and predominantly related to cocaine's adrenergic properties. The increased arterial blood pressure from cocaine's inotropic and chronotropic effects combined with its direct vasoconstrictive effect leads to increased shear forces on the coronary endothelium. This elevated stress may be responsible for the formation of an intimal tear and the subsequent dissection of the coronary artery. If the dissected portion of the arterial wall is displaced enough to significantly occlude the true lumen, infarction can result. In light of this possibility, coronary artery dissection must be considered in young patients presenting with symptoms of cardiac ischemia and a history of cocaine use.     

Spontaneous coronary artery dissection occurs with and without periadventitial inflammation

Dissection of a coronary artery not associated with aortic dissection or trauma is a rare condition that occurs most frequently in peripartum or postpartum women. It has been suggested that localized periadventitial inflammation, often found adjacent to these lesions, may represent a primary vasculitis which causes dissection. Two cases of spontaneous coronary artery dissection are described, together with a brief review of previously published cases. Based on this review, we conclude that periadventitial inflammation is reactive, rather than primary, in nature.     

Isolated fibromuscular dysplasia of the coronary arteries with spontaneous dissection and myocardial infarction

Fibromuscular dysplasia (FMD) is a segmental, nonatherosclerotic vascular disease of unknown etiology. Both the renal and extrarenal arterial FMD may have focally deficient or absent muscular media, and spontaneous dissection is a serious complication of this arterial wall abnormality. Although FMD may be found in virtually any small and medium-sized arteries, to our knowledge, FMD of the coronary arteries previously has not been documented convincingly in the literature. This article describes one such unusual occurrence of FMD in the coronary arteries with spontaneous dissection and myocardial infarction.     

False lumen stent placement during iatrogenic coronary dissection

A 38-year-old woman without significant cardiovascular risk factors was admitted in the coronary care unit with the diagnosis of acute coronary syndrome without ST-segment elevation. In coronary angiography, left coronary artery system was normal in the first contrast injection, but acute occlusion of the left main coronary trunk (LCT) due to iatrogenic dissection was observed in the following. The patient presented marked ST elevation, severe hypotension, hemodynamic collapse, and loss of consciousness. Cardiopulmonary resuscitation (CPR) was initiated, and two drug-eluting stents were consecutively placed in the LCT and the left anterior descending coronary (LAD), but the patient died after 60 min of continuous CPR. The autopsy showed dissection of the LCT and LAD coronaries with both stents placed in the false lumen and hyperacute myocardial infarction in the anterior left ventricular free wall. This case underlines the importance of careful indication of invasive procedures and of taking in consideration their potential risks.     

Multiple spontaneous coronary artery dissections in association with anomalous origin of right coronary and intramural coronary artery dysplasia.

We present a case of sudden death due to spontaneous acute coronary artery dissection. In addition, there was a healing spontaneous coronary dissection, intramural coronary artery dysplasia, and an anomalous origin of the right coronary artery from the pulmonary trunk. The coincidence of multiple spontaneous coronary dissections, coronary arterial dysplasia, and anomalous origin of the right coronary artery is unique.     

Sudden death from coronary artery dissection.

Spontaneous dissection of the coronary arteries is an uncommon condition that may lead to sudden, fatal coronary artery occlusion. Three cases of sudden death attributable to coronary artery occlusion are presented. Dissection was associated with Marfan's syndrome in the first case, and occurred three weeks postpartum in the second case. In case 1, dissection occurred within the intima, and was not associated with an inflammatory cell infiltrate. In cases 2 and 3, dissection occurred between the tunica media and the external elastic lamina, and was associated with a mixed inflammatory infiltrate, rich in eosinophils, T lymphocytes, and histiocytes. The spatial limitation of the inflammatory infiltrate to the adventitial compartment, together with the absence of inflammation in case 1, suggests a reactive origin rather than a causative role for the inflammatory cells. Detailed examination of serial blocks of any coronary artery occlusion is essential in young patients.     

Isolated dissection of the coronary artery: a postmortem study of seven cases

We present the clinical and postmortem findings in seven adults (four females and three males), who died with dissection of the coronary arteries. The median age was 56 years. Five of the coronary artery dissections (CADs) were spontaneous and two followed trauma: one a motor vehicle accident, the other occurred during angiography. Four cases died suddenly or within 30 minutes. Three had symptoms of at least 24 hours duration and, not unexpectedly, had histological evidence of myocardial infarction. Four dissections involved the left anterior descending coronary artery, two the right coronary artery and one a dominant circumflex artery. Histological examination of the dissected arteries in four cases demonstrated necrosis of the medial smooth muscle which was intimately related to intimal tears and/or an inflammatory reaction. From a review of the literature and this study of seven cases, we conclude that CAD is multifactorial in causation and has a wide spectrum of clinical presentations. Presently the role of coronary vasospasm and prior trauma appears underestimated, and in many cases of CAD the nature of the primary initiating event remains open to speculation.     

Isolierte spontane Koronararterien-Dissektion

Summary A complete review of the literature on the disease entity isolated spontaneous coronary artery dissection (72 ascertained cases with our own three) is given. The emphasis is placed on differential diagnosis of coronary heart disease, particularly in young patients without typical atherosclerotic risk factors. Isolated spontaneous coronary artery dissection is defined as a spontaneously dissecting hematoma limited to one or more coronary arteries. Women are involved considerably more frequently than men (84% of cases). Mean age at onset of the disease is 41 years (range: 21–70 years). The main site of involvement is the left coronary artery (79% of cases). In one-third of the female patients there is a temporal relationship to pregnancy (peripartum coronary artery dissection). Three types can be differentiated by coronary arteriography. Less than one-third of the patients survive the first 24 h after acute onset of symptoms; attempts at emergency reperfusion of the ischemic myocardium by aortocoronary bypass surgery or thrombolytic therapy have not been successful.

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Abkürzungsverzeichnis ISKD isolierte spontane Koronararterien-Dissektion - RIA Ramus interventricularis anterior - i.c. intrakoronar - LH linkskoronarer Hauptstamm - R rechte Koronararterie - L Lumen - DK Dissektionskanal     

Acute myocardial infarction caused by coronary artery dissection following blunt chest trauma

Chest trauma can lead to various cardiac complications ranging from simple arrhythmias to myocardial rupture. An acute myocardial infarction (AMI) is a rare complication that can occur after chest trauma. We report a case of 66-year-old male who suffered a blunt chest trauma from a traffic accident resulting in an AMI. The coronary angiography revealed an eccentric 50% narrowing of the ostium of left anterior descending artery (LAD) by a dissection flap with calcification. Intravascular ultrasonography (IVUS) revealed eccentric calcified plaque (minimal luminal diameter [MLD]=3.5 mm) with a dissection flap. Intervention was not performed considering the MLD and calcified flap, and he has been conservatively managed with aspirin and losartan for 2 years. The follow-up coronary angiography showed an insignificant luminal narrowing of the proximal LAD from the ostium without evidence of a dissection. An early coronary evaluation including an IVUS study should be considered for managing patients who complain of ongoing, deep-seated chest pain with elevated cardiac enzyme levels and an abnormal electrocardiogram (ECG) after a blunt chest trauma. Based on this case, some limited cases of traumatic coronary artery dissections can be healed with conservative management and result in a good prognosis.     

An autopsy case of aortic dissection due to giant cell arteritis

Giant cell arteritis (GCA) is a systemic vasculitis affecting mainly large and medium-sized arteries. GCA sometimes involves the aorta and its major branches and causes aortic dissection as a rare complication. We have experienced an autopsy case of aortic dissection due to GCA. The patient was an 87-year-old Japanese woman with Stanford type A aortic dissection who died 7 days after admission. Two years previously she had been diagnosed as having abdominal aortic aneurysm and undergone endovascular aneurysm repair (EVAR). Although she had no characteristic symptoms of GCA, autopsy revealed marked granulomatous inflammation in the dissected area and coronary arteries. Active arteritis was evident not only in the arteries of the upper extremity but also those in the lower extremity. Granulomatous inflammation was not evident in the aneurysm. The aortic dissection might have been an initial manifestation of GCA. We report the regions of GCA extension and its histology in detail.     

Homocysteinemia is a risk factor for aortic dissection

There are significant associations between moderate increases in serum homocysteine and three cardiovascular diseases: ischemic heart disease, deep vein thrombosis and pulmonary embolism, and stroke. An association between the presence of abdominal aortic aneurysm and elevated homocysteine plasma levels has been indicated. Although chronic systemic hypertension is the most common factor predisposing the aorta to dissection, homocysteinemia has never been known as the risk for aortic dissection except for that with Marfan syndrome. Homocysteinemia is suggested to be the risk for aortic dissection in Marfan syndrome and spontaneous cervical artery dissection. Reduced fibrillin-1 deposition into the extracellular matrix is found not only in Marfan syndrome but also in isolated ascending aortic aneurysm and dissection. The reduced matrix deposition produces a mild form of weakness of elastic tissue, which predisposes to ascending aortic aneurysm and dissection in patients who do not have the Marfan syndrome. The defect in fibrillin-1 leads to: (1) formation of elastin that is abnormally aggregated and more easily degraded by matrix metalloproteinases than is normal elastin; (2) upregulation of the synthesis of matrix metalloproteinases; (3) progressive destruction of connective tissue by these enzymes; (4) development of thoracic aortic aneurysms. Homocysteine causes premature breakdown in the arterial elastic fibers by activation of the elastolytic activities. Irreversible homocysteinylation of long-lived proteins should lead to cumulative damage and progressive clinical manifestations, and fibrillin-1 is seen as the paradigm of extracellular connective tissue proteins that are specially susceptible to homocysteine (and presumably homocysteine thiolactone) attack. The authors hereupon propose a novel hypothesis that homocysteine plays an important role in development of aortic dissection and that homocysteinemia is one of the risk factors for aortic dissection.     

Pulmonary artery dissection in patients without underlying pulmonary hypertension

AIMS: Pulmonary artery (PA) dissection is a rare event which usually occurs in patients with underlying pulmonary hypertension. We describe two patients who developed PA dissection without pre-existing pulmonary hypertension and present an extensive review of the literature. METHODS AND RESULTS: In the first patient (a 59-year-old woman), acute-onset dyspnoea was initially thought to have been caused by pulmonary thrombosis, and thromboendarterectomy was performed. Histologically, pulmonary dissection without external rupture was evident, chiefly in the right main PA. In the second patient, an 85-year-old man who had hypergammaglobulinaemia of unknown cause and died from a haemorrhagic gastric ulcer, arterial dissection was detected at autopsy. There was no underlying pulmonary hypertension in either patient. Although the true reason for the development of dissection is unclear, pre-existing inflammation was considered to be related to its formation, at least in the second case. CONCLUSIONS: A literature review indicated that idiopathic and inflammation-related PA dissection is extremely unusual. Since PA dissection is very rare, it is important to be aware of its features in order to make a correct diagnosis.     

Modification of pathologo-anatomic method of heart dissection after valve prosthesises implantation

Modification of the method of heart dissection in patients who died after valve replacement is suggested. After standard atrial cutting dissection of the ventricles is made from the apex along the interatrial fissure without cutting the proximal regions of the coronary arteries. The method allows good inspection of the ventricular cavities and elucidation of the relationships between anatomical structures and artificial valves.     

Percutaneous transluminal coronary angioplasty guidewire-induced coronary artery dissection without balloon inflation

A case of arterial dissection of the right coronary artery secondary to angioplasty guidewire manipulation is presented. No balloon inflation was performed. The histologic appearance of the involved arterial segment was similar to that found in the left anterior descending coronary artery, which had undergone successful balloon dilatation. Both arteries demonstrated medial disruption and fibrointimal proliferation. The pathologic features of angioplasty-induced vascular injury may occur with or without balloon inflation.     

Left main coronary artery dissection after blunt chest trauma presented as acute anterior myocardial infarction: assessment by intravascular ultrasound: a case report.

Coronary artery injury after blunt chest trauma is very rare, but this can result in a serious acute myocardial infarction. Coronary artery dissection is an uncommon complication of thoracic injuries. We report a case of a 17-year-old male who was presented with an anterior myocardial infarction following blunt chest trauma after a bicycle accident. His coronary angiography revealed aneurysmal dilatation with dissection of the distal left main stem coronary artery. Intravascular ultrasound showed a dissecting flap at the left main stem coronary artery. The patient was treated conservatively and discharged without serious sequelae. When symptoms and electrocardiographic findings are compatible with acute myocardial infarction, careful evaluation is important in patients with thoracic injuries for proper management. If the patient is stable, medical therapy may be appropriate. But early intervention should be considered in the presence of ongoing myocardial ischemia.     

Carotid artery dissection in an adult with the Simpson-Golabi-Behmel syndrome

We report on the case of a 44-year-old man affected with the Simpson-Golabi-Behmel syndrome (SGBS) (OMIM 312870) presenting with ischemic stroke due to a dissection of the right internal carotid. Molecular genetic analysis revealed the p.Gly556Arg mutation in exon 8 of the gene encoding glypican 3 (GPC3). This is the second case of a GPC3 missense mutation to be reported. The only risk factor found in this patient was carotid redundancy, a deformation that is significantly associated with spontaneous carotid dissection. The natural history of SGBS in adults is poorly known, and this case raises the question of a possible vascular risk associated with the disease.     

Takayasu aortitis with acute dissection and hemopericardium

We report a case of a 57-year-old woman with an unremarkable past medical history who presented to the emergency department with maxillary pain that later radiated to the chest. She died less than 12 h after admission. CT findings were consistent with ascending aorta dissection with hemopericardium. Autopsy revealed a tear immediately proximal to the ostium of the brachiocephalic artery and a dissecting flap with false lumen, rupture, and hemopericardium. Histologically, there was a zonal medial necrosis with surrounding chronic inflammation, focal destruction of the media, and fibrosis of the intima and adventitia. A diagnosis of granulomatous necrotizing aortitis of Takayasu type was made. This case demonstrates a rare example of aortitis underlying aortic dissection and emphasizes the need for careful histologic examination in cases of aortic root disease.     

Pathogenesis of spontaneous cervico-cerebral artery dissection. A hypothesis and a review of the literature

The pathogenesis of spontaneous cervico-cerebral artery dissection remains speculative due to the rarity of histopathological observations, which often correspond to late stage lesions. Transposition of theoretic data from experimental models, study of pathologies with morphological lesions of the same type, and review of some clinical cases, suggest a sequence for the pathological events leading to arterial dissection. Arterial dysplasia, aneurysms and dissections could all result from vascular remodeling in response to endothelial injury. It induces morphologic changes of the internal elastic lamina, smooth muscle cell proliferation, various matrix abnormalities involving the fibrillary components or their enzymatic regulation, arterial wall neoangiogenesis and dissection. Endothelial dysfunction could so play a key role in the imbalance between arterial degenerative and reparative processes and the initiation of cervico-cerebral artery dissection.     

Eosinophilic coronary periarteritis (vasospastic angina and sudden death), a new type of coronary arteritis: report of seven autopsy cases and a review of the literature

A previously reported autopsy case of eosinophilic coronary periarteritis (ECPA, or isolated eosinophilic coronary periarteritis, IECPA), and an additional six autopsy cases of ECPA are reported. In addition, another four autopsy cases of ECPA reported in the literature are discussed. Fifteen cases of ECPA with spontaneous coronary dissection (hematoma), which appeared in the literature from 1987 to 2011, are also reviewed. The characteristic clinico-pathological findings of ECPA are: (a) variant angina (Prinzmetal’s vasospastic angina) appeared mainly from evening to early in the morning; (b) allergy or allergic history could be identified in only three of a total of 11 cases; (c) sudden unexpected death (sudden cardiac death) usually occurred early in the morning; (d) eosinophilic inflammation limited to the adventitia and periadventitial soft issue appeared in the epicardial large coronary arteries, chiefly in the left coronary anterior descending artery; (e) fibrinoid necrosis or granuloma could not be found in or around the inflammatory area; (f) no type of vasculitis could be found in any other tissues or organs (i.e., localized and non-systemic periarteritis); (g) ECPA was frequently accompanied by spontaneous coronary arterial dissection (SCAD) in the affected wall; and (h) ECPA without SCAD appeared mainly in men (male/female ratio was 8:3), while EPCA with SCAD appeared in almost all female cases (male/female ratio was 1:14). Although the etiology and pathogenesis are still unknown, we believe that ECPA (with or without SCAD) might be a distinct new type of coronary arteritis.